ABC | Volume 113, Nº4, October 2019

Viewpoint Cardiology Training in Brazil and Developed Countries: Some Ideas for Improvement Lucas Colombo Godoy, 1,2 Michael E. Farkouh, 2 Isabela C. K. Abud Manta, 1 Talia F. Dalçóquio, 1 Remo Holanda de Mendonça Furtado, 1,3 Eric H. C. Yu, 2 Carlos Gun, 4 José Carlos Nicolau 1 Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, 1 São Paulo, SP – Brazil Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, 2 Toronto, ON – Canada Brigham and Women´s Hospital, Harvard Medical School, 3 Boston, MA – USA Instituto Dante Pazzanese de Cardiologia, 4 São Paulo, SP – Brazil Mailing Address: José Carlos Nicolau • Unidade de Coronariopatia Aguda (UCCA) do Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Av. Dr. Enéas de Carvalho Aguiar, 44, 2 andar, sala 12. Postal Code 05403-900, São Paulo, SP – Brazil E-mail: corjnicolau@incor.usp.br Manuscript received February 15, 2019, revised manuscript May 07, 2019, accepted June 04, 2019 Keywords Cardiology; Education, Medical; Program Accreditation; Internship and Residency; Fellowships and Scholarships; Brazil. DOI: 10.5935/abc.20190212 Abstract Huge variations exist in cardiology training programs across the world. In developing (middle-income) countries, such as Brazil, to find the right balance between training improvements and social and economic conditions of the country may be a difficult task. Adding more training years or different mandatory rotations, for instance, may be costly and not have an immediate direct impact on enhancing patient care or public health. In this text, we compare the Brazilian cardiology training systemwith other proposals implemented in developed countries from North America and Europe, aiming to point out issues worth of future discussion. Factors such as training rotations and competencies, and program duration and distribution across the countries are presented. The number of first year cardiology trainees per inhabitants is similar between Brazil and the United States (0.24 medical residents/100,000 inhabitants in Brazil and 0.26 medical residents/100,000 inhabitants in the USA). These numbers should be analyzed considering the inequality in training program distribution across Brazil, since most centers are located in the Southeast and South regions. Having more residency programs in distant areas could improve cardiovascular care in these areas. Duration of cardiology Residency Training is shorter in Brazil (two years) in comparison with developed countries (> 3 years). Brazilian residency programs give less emphasis to scientific research and diagnostic methods. Unifying minimum training requirements across the globe would facilitate the development of international learning opportunities and even professional exchange around the world. Introduction Brazil is the fifth largest country in the world, regarding both land territory and population, and it is the tenth largest economy globally. 1,2 As well as in many other developing and developed nations, cardiovascular diseases are a major concern in Brazil, being the leading cause of death in the country. 3 On the other hand, many Brazilian citizens do not receive proper cardiovascular care. 4 Improving health professionals’ training may contribute to change this scenario, although the understanding of what modifications should be made in cardiology training programs is not an easy task. Drawing parallels between the cardiology residency programs in Brazil and other countries’ programs may help to identify possible targets for improvement. However, there are few publications currently available on cardiology training programs. 5 The main objectives of this report were 1) to delineate a non-systematic narrative point-of-view, comparing the Brazilian training system with countries in Europe and North America; 2) to briefly introduce the cardiology training program in Brazil to international readers who may not be familiar with it. PubMed database was searched for articles published up to February 2018 with the keywords “cardiology Residency” and “cardiology Training” in the target countries, written in English, Spanish and Portuguese. Official position statements and legal documents issued by cardiovascular societies and public organizations pertinent to this topic were also reviewed and cited as appropriate. Selection of countries was made based on the availability of information in the literature. Given the nature of the present article, and the scarcity of published data, authors’ opinions were also included when appropriate. Length of Training To become a cardiologist in Brazil, the first step is to obtain a medical degree. After finishing high school, the student must apply for a highly competitive entrance exam (called “vestibular”) and be admitted to a medical degree course, which lasts six years. The following step is a two-year internal medicine residency and, finally, the general cardiology residency (named Fellowship in some countries, such as the USA), which lasts two more years. To be a specialist in a field of cardiology, additional training is required. For example, for training in imaging techniques (echocardiography, cardiac magnetic resonance, nuclear medicine, etc.), usually one or two additional years are necessary for each track. The same amount of time is normally required for some clinical subspecialties, such as Acute Coronary Care, and two years are mandatory for Interventional cardiology. For Heart Failure and Transplantation, one extra year is required. In summary, to become a Cardiologist in Brazil one needs to complete four (General Cardiologist) to six (General 768