"Cancel the Consult:" Bridging the Gap Between Cardiology and Primary Care

This is the second installment of the Care Transformation Blog Series. Get caught up by reading blog #1.

As I work with cardiologists in organizations across the U.S., I hear a very common theme: the frustration that consults and referrals that don’t require a cardiologist are overburdening cardiology clinics. Each time I hear this, it takes me back to my early clinical days. When one particular cardiologist would come across a consult he felt was unnecessary, he would suggest in a loud, booming voice that we simply, “Cancel the consult.”   

Interestingly, it was a cardiologist’s opinion that these consults and referrals don’t require a cardiologist. Behind those consults and referrals are ordering physicians and clinicians who at some point felt the patient indeed needed to be seen by a cardiologist. I would suggest this common scenario represents a mismatch between expectations and presumed needs.   

Yes, this is the reality for both parties – most cardiology programs have more patients than they can see in the appropriate timeframe, making lower-acuity, new patient referrals frustrating rather than welcome. Primary care providers have patients with needs they feel they can’t address safely and effectively without assistance from cardiology. 

This entire scenario got me thinking about how cardiology can better partner with primary care partners, which may reduce the need for some of these consults and improve our patient, physician and provider experiences if done effectively. Let’s start by understanding the current state of primary care in the U.S.   

It’s important to understand several key primary care statistics:  

• Fewer medical school graduates are choosing to go into primary care as their final professional designation than in the past. In 2024, 2,260 residency slots went unmatched between family practice and internal medicine.¹    
• According to the 2023 compensation data for primary care published by The National Center for Workforce Analysis, the average family practice earnings were $255,000, and the average earnings for internal medicine were $273,000.² The average medical school debt is $234,597, excluding premedical undergraduate and other educational debt.² The math here is daunting.   
• The Association of American Medical Colleges (AAMC) anticipates a shortage of primary care physician between 20,000 and 40,000 by 2036 (Figure 1).³  

Figure 1: Projected Primary Care Physician Shortfall Range, 2021-2036 

Reproduced from GlobalData Plc. The Complexities of Physician Supply and Demand: Projections From 2021 to 2036. Washington, DC: AAMC; 2024. Accessed February 28, 2025. https://www.aamc.org/media/75236/download?attachment. 

• According to the Health Resources and Service Administration, the adequacy of primary care physicians by 2026 is only 81%, with the rest made up by advanced practice providers (APPs) (Figure 2).⁴   

Figure 2: National Estimated Percent Adequacy by Provider Type, 2036 

Reproduced from Department of Health and Human Services, Health Resources and Services Administration, Health Workforce Projections. HRSA.gov. Accessed February 28, 2025. https://data.hrsa.gov/topics/health-workforce/workforce-projections. 

• In order to fill this gap, APPs have been added to primary care delivery both in teams and independent practice. The addition of primary care providers is a viable and necessary reality. However, it must be respectfully noted that the education and skillset for APPs is different than the education and skillset for physicians.
• A recent analysis by Health Atlas shows the following breakdown of providers in several primary care organizations. The key take-home message is that non-physician providers deliver a significant portion of primary and urgent care.⁵   

Most primary care programs are trying to do more with less, likely on an even broader scale than what we are experiencing in cardiology. Given these challenges, how do we create an environment to make it easier for our primary care partners to manage their patients? I would suggest that we need to think beyond the traditional consult/referral relationship.   

To that end, there are several ways to better partner with primary care: 

1. Education: There are few educational methods more powerful than learning from your peers. When local physicians and clinicians educate one another, they build relationships and can easily apply new knowledge. In a recent listserv survey, MedAxiom found that many organizations are not providing local education as they have in the past. Activities such as broadly attended grand rounds, local cardiovascular CME symposiums, and shared journal clubs have declined. These are great ways to provide updates on cardiovascular patient management and get to know your primary care partners in a different context. One goal of these activities is to make the education actionable. These activities provide opportunities not only for clinical education but also for establishing appropriate referrals by sharing when and how to refer to cardiology. 
2. Clinical Decision Support Mechanisms (CDSMs): For organizations fortunate enough to have primary care and cardiology in the same electronic health record (EHR), establishing CDSM tools can lead to great insights in diagnosis, treatment and ultimate referral needs for common cardiovascular conditions. When cardiology owns or collaborates with primary care on the authorship and development of these cardiology care tools, they provide a very effective way of aligning and assuring appropriate management and referrals.   
3. Cardiology-Defined Care Pathways: Another version of CDSMs cardiology-defined care pathways can be delivered to primary care (and others) through electronic apps or websites. Care pathways outline initial evaluation and management steps for common cardiology conditions and provide low-effort ways to engage in either an e-consult or full consult when appropriate. A great application of this example would be for a patient with palpitations. The care pathway would define the initial diagnostic plan and then an algorithm with when to consult cardiology. These tools can improve patient management from the initial presentation in a primary care setting.   
4. E-consults: Many cardiology programs have adopted an e-consult option for low-acuity cardiology issues or questions. Patient findings such as abnormal electrocardiogram or patient symptoms, such as palpitations, benefit from an initial virtual cardiology review to assist with further diagnostic requirements or definitive opinions on whether there is a true cardiology concern or not. These activities are billable when appropriately documented, minimize unnecessary face-to-face referrals, provide access to cardiology, and support the development of relationships with referring physicians through enhanced service and support (Figure 3).

Figure 3: Two Options for Interprofessional Consults

Modified from MedAxiom. 2024 Coding Bootcamp Series. MedAxiom Academy. 

Finally, I want to leave you with something to think about when it comes to our partners who deliver primary care. The landscape has not only changed but so has the ability for cardiology and primary care to interact and collaborate effectively.   

Twenty years ago, prior to the introduction of hospitalist medicine, the majority of primary care physicians came to the hospital to manage their patients. That model created an environment where cardiologists and primary care physicians had face-to-face interactions on a routine basis. This is no longer the case.   

Most primary care physicians and teams know cardiology by name only. The personal relationship has devolved, and the need to reconnect in other ways is real. Whether through the activities outlined above, improved communication in consult/referral notes, or picking up the phone to collaborate on patient care, we need to reconnect with our primary care partners in a collaborative, respectful way that allows us to share care appropriate and effectively.   

Our patient outcomes depend on it.   

Reference: 

1. Jain S. Match Day 2024: Primary Care Residency Positions Continue to Go Unfiltered. TrilliantHealth.com. Published April 7, 2024. Accessed February 28, 2025. https://www.trillianthealth.com/market-research/studies/match-day-2024-primary-care-residency-positions-continue-to-go-unfilled. 
2. Hanson M. Average Medical School Debt. EducationData.org. Published August 28, 2024. Accessed February 28, 2025. https://educationdata.org/average-medical-school-debt. 
3. GlobalData Plc. The Complexities of Physician Supply and Demand: Projections From 2021 to 2036. Washington, DC: AAMC; 2024. Accessed February 28, 2025. https://www.aamc.org/media/75236/download?attachment. 
4. Department of Health and Human Services, Health Resources and Services Administration, Health Workforce Projections. HRSA.gov. Accessed February 28, 2025. https://data.hrsa.gov/topics/health-workforce/workforce-projections. 

5. Miu P. The Evolving Primary Care Workforce. XPrimaryCare.com. Published Sept. 6, 2024. Accessed March 1, 2025. https://www.xprimarycare.com/p/the-evolving-primary-care-workforce.

Illustration by Lee Sauer