ABC | Volume 113, Nº4, October 2019

Viewpoint Godoy et al. Cardiology training in Brazil Arq Bras Cardiol. 2019; 113(4):768-774 Table 1 – Length of cardiology residency trainings in selected countries. 10-12,21,25,33,34 Country Continent Graduation (years) Previous training length (ys) (e.g.: internal medicine) Cardiology residency program (years) Total length (years) Australia Oceania 6 4 3 13 Brazil South Am. 6 2 2 10 Canada North Am. 7 or 8 3 3 13 or 14 France Europe 6 1 3 10 Germany Europe 6 3 3 12 Spain Europe 6 1 4 11 UK Europe 5 4 or 5 5 14 or 15 USA North Am. 8 3 3 14 Am.: America. Data obtained from each country’s official legislation or decree on medical training and/or National Cardiovascular Society Cardiologist with a subspecialty training) years of postgraduate medical education. It is important to note that the National Board of Medical Residency (“ Comissão Nacional de Residência Médica ” – CNRM) supervises the residency training (as will be discussed later) and some (but not all) of the subspecialties training programs. When comparing education and training lengths between developed and developing countries, important differences are observed (Table 1). Ten years are required to become a general cardiologist in Brazil (which is similar to most countries in Latin America). 6-9 In the USA, internal medicine residency and cardiology Fellowship usually last three years each. Adding that to the period in the undergraduate degree program and in Medical School (eight years), the total post-secondary education time to become a cardiologist in the USA is 14 years. In Germany, three years of internal medicine residency training and three years of cardiology residency training are required (12 years in total). There are also differences in patterns of work shifts across the countries, which may influence the real time spent in training. Post‑call day-off, for example, is a common practice in the USA and Canada, while in Brazil the resident is allowed six hours of rest (instead of the whole day) following a night-shift work. After the completion of the whole educational program straightly, that is, without interruptions for conscription, or extra or sabbatical years, a doctor will be able to become a cardiologist approximately at the age of 28 in Brazil, 33 in the USA and 31 in Germany. 10,11 Another example of a lengthy training process can be observed in the United Kingdom. After finishing medical school (usually five years), the trainee must complete a two‑year Foundation Program, followed by the Core Medical Training (two years) or Acute Care Common Stem (three years). After that, the trainee is finally able to go through the specialty training in cardiology. That is comprised of three initials years of Core Cardiology Training and two years of advanced training in specialist area modules. During the three initial years, the emphasis is given to acute cardiovascular care and basic procedural techniques. For the last two years, most of the time is spent in one or more of these fields of practice: interventional cardiology, electrophysiology, non‑invasive imaging, adult congenital heart disease or heart failure. Counting all those years together, a total of 14 or 15 years is required to become a cardiologist in the UK. Of note, after the completion of this pathway, not all cardiologists will have the same amount of knowledge in every area, since the curriculum for the last years is flexible to the individual’s interest. Additional years may be necessary for those doing part-time training, or for dual certification in cardiology and internal medicine, or for combining out-of-program research (by doing a research fellowship in another institution, for example) or extra training in subspecialties of cardiovascular care. 12,13 Clearly, the duration of training to become a cardiologist is not uniform across countries, and there is not a definitive standard of practice. It depends not only on the total amount of knowledge and practical skills that the professional needs to acquire, but also on the country’s social and economic conditions, since having more training years increases educational expenses. As a general guidance, the American College of Cardiology (ACC) endorses the period of three years for training in general cardiology while the European Society of Cardiology recommends a four-year term, despite important variations among European countries. 14,15 Using a comparative approach only, it is not possible to accurately state that the same length of training in these countries would be applicable to the Brazilian reality. It may be the case that medical residents in Brazil spend more time in service during the two-year residency and oversee more patients. Conversely, the amount of knowledge in cardiology has increased dramatically in the last decades 16 and it seems unlikely that a resident in cardiology resident in Brazil would be able to master the necessary knowledge and abilities in a 2-year training duration. As a result, there is an ongoing discussion in Brazil to have a single focused year of internal medicine training (instead of the current two years, as in France and Spain) before starting a new model of a 3-year cardiology residency. Required competencies and training schedule To better understand how knowledge is acquired, one may also look at the core rotations trainees must complete. The government sector responsible for the coordination of medical training throughout Brazil is the Ministry of Education (with active participation of the Ministry of Health), and the CNRM. 17 The CNRM was founded in 1977 and has made several improvements to the medical residency, as follow: 769