To the Editor:

The lack of cardiologists (and of other specialists) is a serious problem that occurs, among other things, because of the poor vision of politicians. Thus, at this point, it would be dangerous to leave them to deal with this issue alone. For this reason, we welcome the fact that the Spanish Society of Cardiology offers this article,1 with respect to which I would like to make a few comments.

1. Concerning the "shortcut" for training clinical cardiologists. In the United States (35th Bethesda Conference),2 cardiologists of this type are mostly found in private medicine. In Europe, with its public health systems, this shortcut is not an option, at least as far as we know.

The clinical cardiologist is a key figure and should be highly trained and experienced (the "long way around"). In fact, the lack of good clinical cardiologists has also been lamented in the United States.3 The existence of "first class" and "second class" cardiologists in the public health system would create professional envy, as has already occurred with the "MESTOS" (medical specialists without official degrees). The Spanish Society of Cardiology should never downgrade cardiologic training, quite the contrary. We should not respond to the lack of cardiologists by creating a group of aides to work in the ambulatory setting.

2. Concerning the importation of cardiologists. This would be possible if the salaries were raised; otherwise, we would import cardiologists from poorer countries with questionable training. The relaxation of the minimum training criteria required of foreign cardiologists is always a bad move.

3. Concerning the modification of the structure of the cardiology services and the integration of physicians who are not cardiologists. This, I feel, is the road to follow. The plan should: a) increase the number of cardiology interns; b) redistribute the cardiologists we have; and c) incorporate general practitioners involved in the treatment of cardiovascular diseases.

For the redistribution, according to my criteria (and this is the case in the service in which we work), all the units, even those most highly subspecialized, have an assigned ambulatory office. This increases ambulatory care (which is the problem), gets everyone in contact with clinical reality, improves the indications for tests and rectifies the "superiority of the superspecialist."

Rather than creating the "shortcut clinical cardiologist," it would be better to train internists in the major cardiologic problems encountered in the ambulatory setting, as is pointed out in the article. The results would be similar and the downgrading of the specialty would be avoided. The "generalist-cardiologist" was also discussed in the United States in its day.4 This figure is conceptually different from the "shortcut" cardiologist.

Internal medicine is in crisis. Internists have to enter the ambulatory setting5 to act as a filter. We feel that, in six months of guided immersion, the internist can acquire the necessary training in cardiology to fulfill this new function. The training period would have to be repeated for two or three months every two years. Something similar, with certain variations, could be done with primary care, which is also in crisis.6

4. Concerning the reduction in demand. It is one thing to reduce the incidence and prevalence of cardiovascular diseases (a difficult feat, as is pointed out in the article) and another to reduce unnecessary visits to the cardiologist. This would be addressed by the involvement of the internist in cardiological care, as well as by the famous "copayment" (always protecting the weak). Over a cup of coffee, politicians accept copayment, but they will never put it into practice since, in politics, courage is equivalent to suicide.

In conclusion, the attempt to alleviate the lack of cardiologists requires a long-term plan to be reviewed every two years. For this purpose, the Spanish Society of Cardiology has to meet with the societies of Internal Medicine and Primary Care, to get them to reorganize training according to the current needs. The new plan, once completed, would be presented to the politicians involved in health care, who almost never make long-term plans.