The structure of departments of cardiovascular medicine at university hospitals in Germany ^†

In Germany, internal medicine usually is divided into different sub-specialities (Table 1). In all locations, cardiology was among the 16 different sub-specialities. Figure 1 shows the distribution of the number of sub-specialities per location. As an example, Figure 2 gives the structure of the Departments of Internal Medicine at the University of Münster. In more than half of all locations, there were either 3 or 4 departments of sub-specialities of internal medicine. More than 4 (up to 8) sub-specialty departments existed in only one location each. Thus, a total of 3 to 4 departments seems to be considered as the “optimum” by most faculties. Sub-specialities most frequently represented by separate departments, besides cardiology that was present in all locations that responded, included gastroenterology (n = 23), nephrology (n = 23), and oncology and haematology (n = 23 each).

In these 27 university hospitals, a total of 76 fully tenured professors (C-4) are heads of departments. Another 13 C-3 professors (corresponding to the position of associate professors in a tenured position) exist.

Nearly all cardiological departments have their own medical staff for patient care and for research. Since internal medicine almost exclusively exists in the form of separate departments, 24 of 27 cardiological departments have established a regular rotational program for the medical trainees to offer training within the full spectrum of internal medicine.

Most of the cardiological departments (25 of 27) have a budget of their own. In only two cardiological departments, there is a common budget which is shared between all sub-specialities at these 2 locations.

In 52% of the cardiological departments (14 of 27), the number of beds varies between 50 to 100. In 6 cardiological departments, more than 100 beds are available. In the majority of departments, the proportion of patients who primarily present with a cardiological problem is above 60% (i.e., also patients with other major diagnoses are admitted in a varying proportion). In detail, 5 departments accommodated between 60 to 80%, 8 between 80 to 90%, and 7 more than 90%. In contrast, the percentage of patients with a primary cardiological problem who are admitted to a non-cardiology department, varies between less than 10% in 6 locations, between 10 to 29% in 9 locations whereas there are only 4 locations where 30 to 39% of patients have a primary cardiological problem (Figure 3). However, many patients in the non-cardiology departments also have a cardiological problem requiring consultation by cardiologists.

The number of out-patients who are treated in these 27 cardiological departments differs. In 7 cardiological departments, less than 2000 patients present to the out-patient clinic, in 4 cardiological departments, 2000 to 4000 patients, and in another 5 departments, 4000 to 6000 patients are seen whereas 8 cardiological departments see more than 6000 out-patients per year. In 16 cardiological departments, the number of in-hospital patients ranges between 2000 and 4000. Eight cardiological departments see 4000 to 6000 in-hospital patients but 2 cardiological departments treat even more than 6000 patients.

All cardiological departments are equipped with cardiac catheterization facilities allowing right and left heart catheterization, angiography and interventional techniques. Most perform both electrophysiological studies and interventions. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are integral parts of all cardiological departments as are non-invasive ECG recording and testing facilities.

A variety of special diagnostic and therapeutic techniques is offered at most cardiological departments, sometimes in collaboration with other specialities like radiology, nuclear medicine, and recently, radio-oncology (Table 2).

In almost all cardiological departments, cardiological patients regularly undergo invasive diagnostic procedures and percutaneous interventions, although these patients do not necessarily stay on the cardiological ward. However, the percentage of these patients outside the cardiology departments is quite low (less than 10% in 18 locations, between 10 to 20% and 20 to 30% in 3 locations each). Thus, most of the patients are admitted to and managed in cardiological departments.

Nearly all cardiological consultants (“Oberärzte”) (in 24 of 27 cardiological departments) participate in the consultant service for internal medicine patients. Nearly all cardiological departments (n = 25) offer a permanent service for heart catheterization and coronary interventions throughout 24 hours a day and during weekends and holidays.

The majority of cardiological departments (23 of 27) have their own cardiological intensive care unit on which only the cardiological staff is responsible. In 11 locations, an interdisciplinary intensive care unit for internal medicine altogether exists (the overlap between these two types is explained by the fact, that in some places, both types coexist).

Quite a number of cardiological departments have established clinics for special cardiovascular problems to deal with pacemaker patients, patients with heart failure, patients before and after heart transplantation, patients with peripheral vascular disease, patients with implantable cardioverters/defibrillators, and patients with special rhythm disturbances. Furthermore, one department also manages patients with psychosomatic problems.

In most of the departments, some basic science-oriented research is performed although clinical research dominates (Figure 4). Thirteen of the locations classified more than 70% of their research as clinical research. In contrast, seven locations do more basic science-oriented research than clinical research. The majority of these departments deal with more clinically orientated questions. The minority concentrates on basic science research programs.