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  • 1. The Future of Pediatric Education II: Pediatric Cardiology Page 1 The Future of Pediatric Education II A Project of the Pediatric Community Summary of Survey Findings: Pediatric Cardiology Sponsoring Organizations: American Academy of Pediatrics American Board of Pediatrics Foundation American Medical School Pediatric Department Chairmen Center for the Future of Children of The David and Lucile Packard Foundation Project #MCJ379381 from the Maternal and Child Health Bureau
  • 2. The Future of Pediatric Education II: Pediatric Cardiology Page 2 Introduction The FUTURE OF PEDIATRIC EDUCATION II (FOPE II) Project is a 3 year, grant- funded initiative launched by the pediatric community in May 1996. As part of this project, key leaders in the pediatric community are addressing the future supply and training of pediatricians and the provision of pediatric care into the next millennium. They are continuing the work begun with a 1978 report entitled: "The Future of Pediatric Education." The new report, scheduled for completion in 1999, will contain recommendations that will shape the lifelong learning process of pediatricians. Looking beyond the pediatric workforce and training of pediatricians, the recommendations encompassed in the 1999 report will also address the role and pediatric training of nonpediatricians, the financing of graduate medical education, and primary care and subspecialty issues. The FOPE II Project consists of a 17-member Task Force that has ultimate responsibility for the development of the final report. Operating under the auspices of the Task Force are five, topic-specific workgroups: • Pediatric Workforce Workgroup • Pediatric Generalists of the Future Workgroup • Pediatric Subspecialists of the Future Workgroup • Financing GME Workgroup • Education of the Pediatrician Workgroup Each workgroup will provide an in-depth analysis of key issues under their purview. The workgroups are charged with generating a report that will, to the extent possible, include data-driven conclusions and recommendations for the optimal provision of pediatric care to all infants, children, adolescents, and young adults. An important component of the FOPE II Project has been the gathering of insights, information, and data that will inform the deliberations of the workgroups and the Task Force. A number of venues are being used both to provide and solicit information. One opportunity is the Survey of the American Academy of Pediatrics (AAP) Medical and Surgical Subspecialty Sections. Seventeen AAP medical and surgical subspecialty sections have chosen to participate in this survey process. Several additional sections have provided the data and information that they acquired from independent survey initiatives.
  • 3. The Future of Pediatric Education II: Pediatric Cardiology Page 3 The Survey of AAP Medical and Surgical Subspecialty Sections solicits information about career, education, and practice issues, as well as demographic information. The surveys have been sent to members of the AAP Section, as well as members of the appropriate subspecialty organizations, as identified by the Section. This report summarizes the findings from the surveys of physicians in pediatric cardiology. ©1998 by the American Academy of Pediatrics. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Printed in the United States of America.
  • 4. The Future of Pediatric Education II: Pediatric Cardiology Page 4 Methodology This report is based on responses that were generated from two questionnaires: a standard questionnaire (the Workforce Survey for Child Health Care) and a pediatric cardiology questionnaire (the Pediatric Cardiology Survey). The Workforce Survey for Child Health Care was developed by the FOPE II Task force and was designed to be applicable to most pediatric surgical and medical specialists. The Pediatric Cardiology Survey was developed by two volunteers from the Section on Cardiology, Lourdes Prieto, MD, and W. Jeffrey Dreyer, MD, and the Section's Chairperson, J. Timothy Bricker, MD. This questionnaire, which was mailed to cardiologists along with the standard questionnaire, included questions concerning the number of pediatric cardiology patients seen per week, common diagnostic categories of patients, an evaluation of the number of pediatric cardiologists in the community, numbers and types of pediatric cardiology procedures performed per year, types of training in pediatric cardiology, and types of pediatric cardiology training programs at the respondents' institutions. The surveys were mailed to a sample consisting of the 570 members of the AAP's Section on Cardiology (Section) and the 1,188 US pediatricians who have passed the pediatric cardiology subspecialty board of the American Board of Pediatrics (ABP). Five mailings of the survey went out between January 1998 and May 1998 to a total of 1,234 physicians. (There was significant overlap between the two mailing lists: 42.5% of the sample belonged to the Section and also were subspecialty boarded in pediatric cardiology through the ABP.) Each mailing contained the standard questionnaire and the pediatric cardiology questionnaire, a cover letter emphasizing the importance of the survey, and a return envelope. The survey had an effective sample size of 1,112 and a response rate of 68.1% (757 out of 1,112). Physicians most likely to respond to the survey belonged to the Section and were subspecialty boarded in pediatric cardiology through the ABP (70.8% response rate). Least likely to respond were physicians who belonged to the Section but were not subspecialty boarded in pediatric cardiology through the ABP (23.9% response rate).
  • 5. The Future of Pediatric Education II: Pediatric Cardiology Page 5 Acknowledgments THE FUTURE OF P EDIATRIC EDUCATION II (FOPE II) Project acknowledges the participation of all who facilitated the development and implementation of the Pediatric Cardiology Workforce Survey for Child Health Care and this report on the survey findings. The FOPE II Project Task Force and Workgroup members provided the overall framework for the surveys of pediatric medical and surgical subspecialists and those non-pediatrician physicians who provide pediatric care. The Project is grateful to the members and staff of the American Academy of Pediatrics (AAP). Of particular note are Lourdes R. Prieto, MD and W. Jeffrey Dreyer, MD, volunteers from the AAP Cardiology Section, and J. Timothy Bricker, MD, section chairperson, who wrote the questions for the cardiology questionnaire. Sarah E. Brotherton, PhD, and Judy Karacic of the AAP Department of Research worked diligently on construction of the survey instrument, fielding the survey, and analysis of the results. Thomas M. Gorey, JD, of Policy Planning Associates, wrote the final report. Angela Lipinski, AAP Department of Education, handled all aspects of the production and distribution of this report. The FOPE II Project extends grateful thanks to the many individuals who took time from their busy schedules to complete and return the survey. The participation of these respondents has informed the deliberations of THE FUTURE OF P EDIATRIC EDUCATION II Project. The Future of Pediatric Education II Project is made possible through the support of the following sponsoring organizations: American Academy of Pediatrics, American Board of Pediatrics Foundation, Association of Medical School Pediatric Department Chairmen, Center for the Future of Children of The David and Lucile Packard Foundation, and Project #MCJ379381 from the Maternal and Child Health Bureau. Jimmy L. Simon, MD Project Chairperson Russell W. Chesney, MD Project Vice Chairperson Errol R. Alden, MD Principal Investigator Holly J. Mulvey Director
  • 6. The Future of Pediatric Education II: Pediatric Cardiology Page 6 Workforce Survey for Child Health Care Demographics of Respondents On average, the respondents were 48 years of age and planned to fully retire from the practice of medicine at age 65. Thirteen percent (13%), however, said they expect to retire within the next five years. Eighty percent (80%) of the respondents were male and 20% were female. In terms of ethnicity, 83% were White/Non-Hispanic, 10% were Asian/Pacific Islanders, 4% were White/Hispanic, 1% were African American, and the remainder identified themselves as belonging to other racial or ethnic groups. Eighty-two percent (82.7%) of the respondents were graduates of U.S. medical schools, 1.1% were graduates of Canadian medical schools, and 16.2% were graduates of medical schools in other countries. The respondents’ average year of graduation from medical school was 1976. Specialty, Residency Training, and Board Certification The survey instrument asked respondents to list the specialties and subspecialties in which they have been trained, to specify the year they completed residency training, and to indicate for each specialty/subspecialty listed whether they are board certified. Respondents could list up to three specialties/subspecialties. Table 1 below presents a summary of the specialty, residency training, and board certification information on those who responded to the survey. All but two of the 757 respondents listed pediatric cardiology as one of the specialties in which they had been trained, while 89% also listed general pediatrics. Over 90% of those who listed these specialties indicated that they are board certified. Table 1. Residency Training and Board Certification of Survey Respondents Specialty Number Percent Percent Residency of Total Board Completion Certified Year (#) (%) (%) (Mean) General pediatrics 675 89.2 94.4 1981 Pediatric cardiology 755 99.7 90.6 1985 Critical care 22 2.9 68.2 1990 Neonatology 10 1.3 80.0 1983 Other 20 2.6 45.0 --
  • 7. The Future of Pediatric Education II: Pediatric Cardiology Page 7 Main Practice Site Respondents were asked to specify their main employment site; that is, the setting in which they spend the most time. Table 2 provides a breakdown of responses for this question. For the respondents overall, over one half indicated that their main practice setting was at a medical school, while roughly one out of five said they mainly practiced in a specialty group. Table 2. Main Practice Site Main Site % of Respondents (%) Medical school 56.8 Specialty group 19.1 Solo practice 6.6 Multispecialty group 6.2 Community hospital 3.4 Pediatric group 2.6 HMO 2.2 Community health center 0.8 Uniformed health services clinic 0.5 Other 1.9 When asked to describe the area in which their primary practice site is located, 48% indicated that it is an urban--not inner city--area; 34%, urban--inner city; 14%, suburban; and 4%, rural. Time Spent in Professional Activities Table 3 depicts the average percentage of time spent by pediatric cardiologists in various professional activities. On average, approximately two thirds of the total time spent per week by pediatric cardiologists in professional activities is devoted to direct patient care, while 11% is spent in teaching and 10% is devoted to administration. On average, the respondents said they typically work 61 hours per week.
  • 8. The Future of Pediatric Education II: Pediatric Cardiology Page 8 Table 3. Average Percent of Time per Week in Professional Activities Professional Activity Percentage of Time (%) Direct patient care 66.3 Teaching 11.3 Administration 10.0 Clinical research 5.4 Basic science research 3.2 Health services research 0.4 Resident or fellow in training 0.3 Other, non-direct patient care 3.1 Virtually all of the respondents said they spend some of their direct patient care time in pediatric cardiology, while 21% said they also spend some time in primary care pediatrics. Of the total time spent by the respondents in direct patient care, approximately 94% is devoted to pediatric cardiology, 4% to primary care pediatrics, and the remainder to other specialty areas. Referrals Ninety nine percent (99%) of the respondents reported that they receive referrals for pediatric patients. Table 4 displays the source of these referrals, by specialty. Among those cardiologists who said they receive referrals for pediatric patients, 99% said they receive referrals from pediatric generalists; 92%, from family physicians; 91%, from pediatric medical/surgical subspecialists; and 71%, from pediatric nurse practitioners. Table 4. Source of Referrals of Pediatric Patients to Cardiologists Source of Referrals Percentage (%) Pediatric generalists 98.8 Family physicians 91.7 Pediatric medical/surgical subspecialists 90.5 Pediatric nurse practitioners 70.7 Obstetricians/gynecologists 53.4 Adult medicine subspecialists 52.2 Physician assistants 47.8 General internists 44.3 Others 5.1
  • 9. The Future of Pediatric Education II: Pediatric Cardiology Page 9 The respondents also were asked to report whether they receive referrals from urgent care centers, community agencies, and school districts. Sixty nine percent (69%) of the respondents reported that they receive referrals from urgent care centers, 58% said they receive referrals from community agencies, and 42% indicated that they receive referrals from school districts. Sixteen percent (16%) said they did not receive referrals from any of those three sources. Only 10% of the respondents said that their pediatric referrals come exclusively from within their own practice or managed care network, while 78% said that some of their referrals come from sources outside of their network (roughly 12% said they were not in a network). Among those respondents who reported that they receive referrals, 46% said that neither the volume nor the complexity of the pediatric referrals they have received in the last twelve months has changed compared to previously, while 54% said that either the volume, the complexity, or both have changed. Among those cardiologists who have experienced a change in the volume or complexity of pediatric referrals, 65% indicated that they have seen an increase in the volume of referrals, 21% said there has been a decrease in the volume of referrals, 38% said there has been an increase in the complexity of referrals, and 9% said there has been a decrease in the complexity of referrals. Fourteen percent (14%) said they have experienced no change in the volume of referrals and 53% said they have experienced no change in the complexity of the cases referred to them. Respondents who indicated that they have experienced a change in the volume or complexity of pediatric referrals in the last twelve months were asked to describe the factors to which this change could be attributed (more than one factor could be specified). Thirty eight percent (38%) of the respondents said that an increased likelihood of general pediatricians and other generalists to treat less complex subspecialty patients has caused a change in the volume or complexity of pediatric referrals, while 47% cited increased competition from other pediatric subspecialists as a cause for a change in referrals. Twenty six percent (26%) said that increased referrals from adult subspecialists had caused a change in the volume or complexity of pediatric referrals and 16% said an increased incidence of illness in their community has affected referrals.
  • 10. The Future of Pediatric Education II: Pediatric Cardiology Page 10 Of the respondents who have experienced an increase in the volume of referrals, 48% attributed it to a decreased likelihood of general practitioners to handle complex cases and 30% cited increased referrals from adult subspecialists. Of those who have seen a decrease in the volume of referrals, 86% attributed it to increased competition with other pediatric subspecialists. Of those respondents who have experienced an increase in the complexity of the cases referred to them, 49% attributed it to an increased likelihood of general pediatricians and other generalists to treat less complex subspecialty patients and 30% attributed it to an increase in the incidence or severity of illness in their community. Of those who have seen a decrease in the complexity of referrals, 66% attributed it to increased competition from other pediatric subspecialists. Need for Additional Training Despite whatever changes are taking place in health care, a majority of the respondents do not feel that the changes have resulted in a need for additional training on their part. Seventy five percent (75%) of the respondents indicated that the changes in health care have not necessitated additional training in primary care, and 72% said the changes have not necessitated additional training in their subspecialty. Twenty two percent (22%) of the respondents indicated a need for a “little” additional training in primary care and 26% expressed a need for a little additional training in their subspecialty. Only 3% of the respondents indicated a need for “much more” training in primary care and only 2% indicated a need for much more training in their subspecialty. Competition Eighty four percent (84%) of the respondents said they face competition for pediatric subspecialty services in their geographical area. Among those who said they face competition, the major source of competition (which was mentioned by 88% of the respondents) was other pediatric subspecialists. (See Table 5.) The only other significant source of competition for pediatric cardiologists, which was cited by 44% of the respondents, was “physicians trained in adult medicine in my subspecialty” (i.e., adult cardiologists).
  • 11. The Future of Pediatric Education II: Pediatric Cardiology Page 11 Table 5. Perceived Source of Competition for Pediatric Subspecialty Services Source of Competition Percentage of cardiologists* (%) Other pediatric subspecialists 87.8 Physicians trained in adult 43.9 medicine in my subspecialty Family physicians 1.4 Non-physician medical personnel 1.0 (eg, advanced practice nurses, chiropractors) Urgent care centers 0.7 Related health professionals 0.2 (eg, psychologists, nutritionists) General pediatricians 0.0 Other 4.4 * Percent of respondents who said they face competition from any source Of those respondents who said they face competition for pediatric subspecialty services in their geographic area, only 54% have modified their practice as a result of such competition. Among those who have modified their practices, 45% have increased their office hours, 33% have increased the number of physicians in their practice, and 31% have increased the number and/or responsibilities of support staff (see Table 6). When asked whether, during the last twelve months, their practice had been sold to or merged with another practice or health care organization, only 9% responded affirmatively. Table 6. Practice Modifications as a Result of Competition Change Increased Decreased No Change (%) (%) (%) Office hours 44.7 -- 55.3 Number of physicians for practice 33.1 7.3 59.6 Number/responsibilities of support staff 31.0 9.4 59.6 Number of advanced practice nurses 17.3 2.4 80.3 Amount of research/administrative activities 10.9 21.3 67.8
  • 12. The Future of Pediatric Education II: Pediatric Cardiology Page 12 Fees 7.0 10.3 82.7 Workforce Only one fourth of the respondents said they anticipated their communities would need additional pediatric subspecialists in the next 3-5 years. Thirteen percent (13%) said there would be a need for more pediatric subspecialists in their discipline and 16% felt there would be a need for additional subspecialists in other pediatric subspecialties. When asked whether they or their employer would be hiring additional, non-replacement pediatric subspecialists in their field in the next 3-5 years, 30% of the respondents said “yes,” 40% said “no,” and 30% said they were unsure. Income Cardiologists rely on a variety of payment sources for their income, but straight salaries, along with fee for service, are the most common arrangements (see Table 7). Over one half of the respondents receive some income from straight salaries, while 40% receive some income from fee for service. Just under one third receive some income from salaries with performance incentives, while roughly one fourth receive some income from capitation. Table 7. Sources of Income for Cardiologists Source of Income Percentage With Income from Each Source (%) Traditional fee for service 40.4 Discounted fee for service 40.2 Salary 54.6 Salary with performance incentive 31.2 Prepaid, capitated, nonsalaried 27.2 Prepaid, capitated, salaried 23.9 Table 8 provides information on the percentage of pediatric cardiologists’ income that comes from various sources. Excluding those who said they did not know the breakdown of their total income by source, most of the respondents who said they receive some income from traditional or discounted fee-for-service payment indicated that this source accounts for 33% or less of their total income. Similarly, among those who said they receive some income from prepaid, capitated arrangements--salaried or nonsalaried--most said that this source accounts for 33% or less of their total income. For those who indicated that they receive some income from salaries--or salaries with performance-based incentives--most said this source accounts for two thirds or more of their total income.
  • 13. The Future of Pediatric Education II: Pediatric Cardiology Page 13 Table 8. Percent of Income by Source Income Source 0-33% 34-66% 67-100% Don’t Know Traditional fee for service 57.7 19.5 5.1 17.6 Discounted fee for service 42.9 29.5 8.6 19.0 Salary 11.0 6.2 72.6 10.2 Salary with incentive 19.6 5.6 60.7 14.0 Prepaid, capitated nonsalaried 56.9 15.4 -- 27.7 Prepaid, capitated, salaried 54.0 9.3 8.7 28.0 Finally, when asked whether they have used telemedicine, fax machines or other forms of information technology as part of a consultation with another practitioner because of lack of ready access to appropriate subspecialists (eg, in a rural area), 31% answered affirmatively. Pediatric Cardiology Survey Practice Characteristics The respondents reported that during a typical week they personally see an average of 26 (median of 25) pediatric cardiology patients and an average of 3 (median of 2) adult patients with congenital heart disease. During a typical month, the respondents reported that they personally evaluate an average of 13 (median of 10) newborn patients to exclude congenital heart disease. On average, over three fourths of the respondents’ patients are pediatric patients with acquired or congenital heart disease (see Table 9). Eleven percent (11%) are pediatric patients with a rhythm disorder only and 6% are adult patients with congenital heart disease.
  • 14. The Future of Pediatric Education II: Pediatric Cardiology Page 14 Table 9. Percentage of Pediatric Cardiologists’ Patients by Category Type of Patient Percentage of all Patients (%) Pediatric patients with acquired or congenital heart disease 76.4 Adult patients with congenital heart disease 5.9 Pediatric patients with a rhythm disorder only 11.1 Adult patients with a rhythm disorder only 0.9 Pediatric cardiac transplant patients 1.9 Adult cardiac transplant patients 0.2 Other 3.6 Eighty seven percent (87%) of the respondents said they are directly responsible for providing in-hospital care for pediatric non-surgical cardiac patients and pediatric post- operative cardiac patients. Among these respondents, 97% said they are directly responsible for the in-hospital care of pediatric non-surgical cardiac patients between 8 a.m. and 5 p.m. and 91% said they are directly responsible for the in-hospital care of these patients between 5 p.m. and 8 a.m., while 59% said they are directly responsible for the in- hospital care of pediatric post-operative cardiac patients between 8 a.m. and 5 p.m. and 55% said they are directly responsible for the in-hospital care of these patients between 5 p.m. and 8 a.m. Workforce Issues When asked to evaluate the number of pediatric cardiologists in their area, 57% of the respondents said the supply of pediatric cardiologists was adequate, 37% said the supply was excessive, and 6% said the supply was insufficient. When asked to evaluate the number of pediatric cardiac surgery centers in their area, 55% said the supply was adequate, 42% said the supply was excessive, and 3% said the supply was insufficient. Only 12% of the respondents said they utilize physician’s assistants in their practice. Of those who do, three fourths use 1-2 physician’s assistants and one fourth use three or more. Forty five percent (45%) of the respondents said they utilize nurse practitioners in their practices. Of those who do, approximately 70% use 1-2 nurse practitioners and 30% use 3 or more.
  • 15. The Future of Pediatric Education II: Pediatric Cardiology Page 15 Patient Characteristics Table 10 lists some of the procedures commonly performed by cardiologists for pediatric patients or patients with congenital heart disease. For each procedure, the table displays the percentage of the respondents who said they performed the procedure in 1997 and--for those who performed the procedure--the average (mean) and median number of such procedures performed. Just over 80% of the respondents said they performed transthoracic echocardiography in 1997. Among those who did, 57% said they performed 1-500 procedures; 29%, 501-1000 procedures; and 16%, more than 1000 procedures. Sixty percent (60%) of the respondents said they performed diagnostic cardiac catheterizations in 1997. Among those respondents, 74% said they performed 1-50 procedures; 21%, 51-100 procedures; and 5%, more than 100 procedures. Just over one half of the respondents said they performed fetal echocardiography in 1997. Among those respondents, 39% said they performed 1-20 procedures; 42%, 21-100 procedures; and 19%, more than 100 procedures. Forty six percent of respondents said they performed transesophageal echocardiography in 1997. Among those respondents, 52% said they performed 1-20 procedures; 40%, 21-100 procedures; and 8%, more than 100 procedures. Table 10. Procedures Performed by Pediatric Cardiologists Procedure Percentage Average Median Who Perform Number Number Procedure in 1997 in 1997 (%) (#) (#) Transthoracic echocardiography 82.1 649.1 500.0 Diagnostic cardiac catheterizations 59.6 45.6 40.0 Fetal echocardiography 53.0 73.0 30.0 Transesophageal echocardiography 45.5 44.6 20.0 Interventional cardiac catheterizations 40.4 27.4 15.0 Diagnostic electrophysiology 13.7 81.2 20.0 Radiofrequency ablations 10.5 39.5 32.5 Pacemaker implantations 6.5 15.7 10.0
  • 16. The Future of Pediatric Education II: Pediatric Cardiology Page 16 Forty percent of the respondents said they performed interventional cardiac catheterizations in 1997. Among those respondents, 69% said they performed 1-25 procedures; 16%, 26-50 procedures; and 15%, more than 50 procedures. Fourteen percent (14%) of the respondents said they performed diagnostic electrophysiology in 1997. Among those respondents, 51% said they performed 1-20 procedures; 25%, 21-50 procedures; and 24%, more than 50 procedures. Eleven percent (11%) of the respondents said they performed radiofrequency ablations in 1997. Among those respondents, 39% said they performed 1-25 procedures; 34%, 26-50 procedures; and 27%, more than 50 procedures. Seven percent (7%) of the respondents said they performed pacemaker implantations in 1997. Among those respondents, 63% said they performed 1-10 procedures; 25%, 11-25 procedures; and 12%, more than 25 procedures. Table 11 lists some of the pediatric cardiac surgical procedures commonly performed at the cardiologists’ institutions. For each surgical procedure, the table displays the percentage of the respondents who said such procedures are performed at their primary institution (i.e., the institution at which they spend the majority of their time) and--for those whose institutions do handle the procedures--the average (mean) and median estimated number of such procedures performed per year. (Because there likely were multiple respondents from certain institutions, the estimated number of procedures performed per year at institutions, as reported below, may be somewhat overstated.) For open heart surgery, 20% of the respondents said their institution does not handle that procedure; 28% said 1-100 such procedures are performed per year at their institution; 40%, 101-300 procedures; and 12%, more than 300 procedures. For closed heart surgery, 16% of the respondents said their institution does not handle that procedure; 46% said 1-50 such procedures are performed per year at their institution; 30%, 51-150 procedures; and 8%, more than 150 procedures. For neonatal cardiac surgery, 21% of the respondents said their institution does not handle that procedure; 29% said 1-30 such procedures are performed per year at their institution; 38%, 31-100 procedures; and 13%, more than 100 procedures. Table 11. Pediatric Cardiac Surgical Procedures Performed at Institutions Procedure Percentage Average Median of Institutions Number Number that Handle Performed Performed Procedure per Year per Year (%) (#) (#) Open heart surgery 80.0 157.9 120.0 Closed heart surgery 83.7 63.0 50.0 Neonatal cardiac surgery (<1 month of age) 79.2 54.6 33.0
  • 17. The Future of Pediatric Education II: Pediatric Cardiology Page 17 Arterial switch in neonates 72.2 9.7 6.0 Norwood procedure for hypo plastic left heart syndrome (HLHS) 61.4 8.6 4.0 Pediatric cardiac transplantation 43.4 3.6 NA Thirty nine percent (39%) of the respondents said the Norwood procedure for HLHS is not provided at their institution; 38% said 1-10 such procedures are performed per year at their institution; 15%, 11-25 procedures; and 8%, more than 25 procedures. Twenty eight percent (28%) of the respondents said an arterial switch in neonates is not offered at their institution; 45% said 1-10 such procedures are performed per year at their institution; 20%, 11-25 procedures; and 7%, more than 25 procedures. Fifty seven percent (57%) of the respondents said pediatric cardiac transplantation services are not provided at their institution; 24% said 1-5 pediatric cardiac transplantations are performed per year at their institution; 14%, 5-15 procedures; and 5%, more than 15 procedures. Respondents were asked where they refer patients for cardiac surgical procedures that are not performed at their primary institution. Over one third (34%) of the respondents said their institution does not refer pediatric patients for cardiac surgery. Of those who said their institution does refer pediatric patients for cardiac surgery, 39% said patients are referred to another institution in the same state less than 50 miles away; 36% said patients are referred to another institution in the same state more than 50 miles away; and 54% said patients are referred to out-of-state institutions for cardiac surgery. Medical Education and Training Ninety eight percent (98%) of the respondents said they completed a pediatric cardiology fellowship. Those who completed a pediatric cardiology fellowship on average said that approximately 80% of their fellowship was spent in direct patient care and 20% in research. Eighteen percent (18%) said they received post-fellowship training (not CME) in basic science research; 17%, in pediatric echocardiography; 12%, in pediatric interventional cardiac catheterization; 12%, in pediatric electrophysiology; 4%, in pediatric cardiac transplantation; and 4%, in adult congenital heart disease. Such post-fellowship training programs typically were one year or less in duration. Those who completed a pediatric cardiology fellowship were asked to evaluate the thoroughness of their training in a number of different areas (see Table 12). Sixty four percent (64%) of respondents said computer training should have been addressed more; 56% said they would have liked to have had more training in administration; and 42% thought they could have used more research training.
  • 18. The Future of Pediatric Education II: Pediatric Cardiology Page 18 Table 12. Thoroughness of Pediatric Cardiology Fellowships Area Needed Appropriate Needed More Amount Less (%) (%) (%) Outpatient pediatric cardiology 27.2 70.8 1.9 Inpatient non-surgical pediatric cardiology 5.0 90.6 4.4 Postoperative care of pediatric cardiology patients 22.8 71.3 6.0 Research skills 41.8 50.8 7.4 Administration 55.5 41.7 2.8 Computer training 63.5 35.3 1.3 Seventy one percent (71%) of the respondents said they are affiliated with a teaching institution and, of those who are, 56% said their institution offers a three year pediatric cardiology fellowship program. Respondents who are affiliated with institutions that offer pediatric cardiology fellowship programs indicated that such programs have an estimated average of six fellows each and involve an average of two years of clinical training and one year of research training. Thirty six percent (36%) of the respondents who are affiliated with a teaching institution said that their institution offers a post-fellowship/4th year fellowship (e.g., in interventional cardiac catheterization or electrophysiology), with an average of two fellows in each program.
  • 19. The Future of Pediatric Education II: Pediatric Cardiology Page 19 Summary Over one half of pediatric cardiologists surveyed indicated that their main practice setting was at a medical school, while nearly 20% said they mainly practiced in a specialty group. On average, approximately two thirds of the total time spent per week by pediatric cardiologists in professional activities is devoted to direct patient care, while 11% is spent in teaching and 10% is devoted to administration. Virtually all pediatric cardiologists receive referrals for pediatric patients, with the primary source of referrals being pediatric generalists, family physicians, pediatric medical/surgical subspecialists, and pediatric nurse practitioners. A majority of pediatric cardiologists also receive referrals from urgent care centers and community agencies. Over one half of the pediatric cardiologists who receive referrals say that either the volume of referrals, the complexity of referrals--or both--have changed recently. Almost two thirds of those who have experienced a change have seen an increase in the volume of referrals, due in large part to a growing tendency for general practitioners to handle less complex cases. Most pediatric cardiologists do not feel that recent changes in health care have resulted in a need for additional training on their part--either in primary care or in their subspecialty. Eight out of ten pediatric cardiologists say they face competition for pediatric subspecialty services in their geographical area, with the major source of competition being other pediatric subspecialists, along with adult cardiologists. Just over one half of pediatric cardiologists who say they face competition for pediatric subspecialty services have modified their practice as a result of competition, with the most common change being increased office hours. Only one fourth of pediatric cardiologists anticipate that their communities will need additional pediatric subspecialists in the next 3-5 years.
  • 20. The Future of Pediatric Education II: Pediatric Cardiology Page 20 Over one half of the respondents receive some income from straight salaries, while 40% receive some income from fee for service. Just under one third receive some income from salaries with performance incentives, while roughly one fourth receive some income from capitation. During a typical week, pediatric cardiologists see an average of 26 pediatric cardiology patients and an average of 3 adult patients with congenital heart disease. During a typical month, pediatric cardiologists evaluate an average of 13 newborn patients to exclude congenital heart disease. Eighty seven percent of pediatric cardiologists are directly responsible for providing in-hospital care for pediatric non-surgical cardiac patients and pediatric post- operative cardiac patients. Forty five percent of pediatric cardiologists utilize nurse practitioners in their practices, while only 12% use physician’s assistants. Over three fourths of pediatric cardiologists performed transthoracic echocardiographies in 1997, while over one half performed diagnostic cardiac catheterizations and fetal echocardiographies. Over one half of physicians who have completed a pediatric cardiology fellowship feel that more attention should have been given to training in computers and administration.

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