ABC | Volume 113, Nº4, October 2019

Viewpoint Godoy et al. Cardiology training in Brazil Arq Bras Cardiol. 2019; 113(4):768-774 • Regulation of work hours: currently, a medical resident in Brazil (of any specialty) should work up to 60 hours per week, with no more than 24 hours of in-hospital shift activities (in-home on-call is not permitted); • Wages and salaries: the resident doctor is paid monthly by the Government (Federal, State, or County) or by a private institution. All residents receive the same amount, regardless of the year of training or the field of training (currently there are 53 different medical specialties officially recognized in Brazil). Usually, no extra payment is granted for night shifts. Housing and food assistance are commonly offered, especially for those in greater need. Working at night shifts outside the residency program (“moonlighting”) and “locuming” are not prohibited, as long as they do not interfere with the residency program; • Training supervision: the definition of residency is “training at service under supervision”, which means that the resident must be overseen by an attending physician at all time, including night, weekend and holiday shifts. Once the CNRM requirements are fulfilled, each program has the flexibility to adapt the program according to the local reality. For cardiology, CNRM requires the trainee to spend at least half of the total training time in inpatient care, in the emergency department, wards or coronary care units (CCU). Around one‑fifth of the training time must be dedicated to outpatient clinics, and at least 5% of the time should be spent learning diagnostic methods. Congenital heart disease and post- operative care are also considered mandatory rotations for all cardiology trainees. 18 Importantly, as in North America and some European countries, cardiology residency programs in Brazil are planning to implement a “competency-based curriculum”. This approach is focused on evaluating the trainees according to specific learner outcomes, with emphasis on a formative, instead of a summative assessment, leaving behind the traditional time-based curriculum and passive learning methodology. 19 The discussions are still ongoing, and it will probably take some time until the new proposal is fully implemented in Brazil. In the USA, the Accreditation Council for Graduate Medical Education (ACGME) oversees training programs across the country and establishes general basic requirements for training sites and educators. 10 The ACC also publishes the Core Cardiovascular Training Statement, currently in the fourth version (COCATS 4), with recommendations for levels of trainings and milestones within each component of the cardiovascular training. 14 Both documents from the ACC and ACGME are aligned to and focused on competency‑based learning. The general core competencies are: patient care; medical knowledge; practice-based learning and improvement; interpersonal communication skills; professionalism; and system-based practice. 14 Of note, the Brazilian Society of Cardiology (BSC) also published a guideline for cardiovascular training in the Brazil. 20 In Canada, cardiology training programs are supervised by the Royal College of Physicians and Surgeons of Canada. Along the three-year cardiology Residency Program, the minimum requirements comprehend: 15 training blocks of clinical residency (CCU, wards, consults, clinics), 15 blocks of laboratory‑based residency (cardiac catheterization, electrophysiology, nuclear cardiology, echocardiography), two research blocks, and four blocks of electives. 21 Additionally, clinical and academic contents of the program must fulfill all of the CanMEDS roles for the cardiology specialty. CanMEDS is a “framework that identifies and describes the abilities physicians require to effectively meet the healthcare needs of the people they serve”. 22 According to CanMEDS, medical competencies are grouped under seven key roles: medical expert, communicator, collaborator, leader, health advocate, scholar and professional. 23 Training programs are supposed to offer their trainees opportunities tomaster each one of these roles in the scope of practice. Canada is alsomoving towards implementing a competency-based medical education curriculum for all residency programs, through the “Competence by Design” initiative. 24 This is based onmilestones to be achieved as the resident advances through the training program, from the entrance in the residency program until the transition to the unsupervised medical practice. The target year for Canadian cardiology Residency programs to launch the “Competence by Design” is 2020. In Spain, trainees gain access to the cardiology Residency via the MIR test (“Médico Interno Residente”), right after leaving medical school, and the training lasts five years. In the first year, most of the rotations are usually related to internal medicine. In the second year, activities are divided between CCU, cardiology wards and consults. The third year is dedicated to non-invasive tests, such as echocardiography and cardiac stress tests. In the fourth year, around six months should be spent in the cardiac catheterization laboratory and 4 months in an electrophysiology service. The last year has a more flexible curriculum, at the discretion of each hospital. Residents may rotate on areas such as congenital heart disease and heart transplantation and/or can spend more time doing research and elective rotations. 25 When compared to trainees from North America and some European countries, medical residents in Brazil spend less time in non-invasive tests and in the catheterization laboratory, since those abilities are developed in depth by those who choose to pursue further training in these subspecialties. Training in North America and Europe generally includes completing mandatory, procedural logs and documentation. 10,15,18 In addition, in Brazil, little emphasis is given to research, contrary to countries with longer training length. Residency training programs in Brazil are aimed at practical aspects of cardiology (around 80% of the time), and didactic activities, such as lectures, seminars, etc., are developed in the remaining 20% of total time. Again, changing the residency programduration fromtwo to three years, would also contribute to a better training in important areas, such as research, among others. Availability and distribution of training centers In Brazil, in 2017, 502 new residents a started their training in 167 cardiology Programs, unevenly distributed throughout the regions of the country (average of 0.24 medical residents/100,000 inhabitants); 26 the respective numbers for the USA (2016/2017 period) were 855 newcardiology Fellows in 193 Programs (0.26 new medical residents/100,000 inhabitants). 27 However, the proportion of Cardiologists/100,000 inhabitants in both countries is, respectively, 7.47 for Brazil and 6.83 for the USA 26, 28-30, b (Figure 1). 770