ABC | Volume 113, Nº4, October 2019

Viewpoint Godoy et al. Cardiology training in Brazil Arq Bras Cardiol. 2019; 113(4):768-774 Figure 1 – Comparison between Brazil and the USA(without Puerto Rico) regarding Cardiology Residency (Fellowship) Program distribution. Inhab.: inhabitants. d27,28,30,35 North Area: 1,487,976 sq mi (45%) Cardiology training programs: 3 (2%) Population: 17,707,783 inhab. (8.6%) Central-West and Federal District Area: 620,171 sq mi (19%) Cardiology training programs: 18 (11%) Population: 15,660,988 inhab. (7.6%) Southeast Area: 356,993 sq mi (11%) Cardiology training programs: 88 (53%) Population: 86,356,952 inhab. (42%) South Area: 222,697 sq mi (7%) Cardiology training programs: 29 (17%) Population: 29,439,773 inhab. (14.2%) Northeast Area: 600,115 sq mi (18%) Cardiology training programs: 29 (17%) Population: 56,915,936 inhab. (27.6%) Midwest Area: 821,724 sq mi (21,6%) Cardiology training programs: 48 (25%) Population: 67,941,429 inhab. (21%) Northeast Area: 181,320 sq mi (4.8%) Cardiology training programs: 58 (30.2%) Population: 56,209,510 inhab. (17.4%) South Area: 920,446 sq mi (20.2%) Cardiology training programs: 56 (29.2%) Population: 122,319,574 inhab. (37.9%) West Area: 1,873,252 sq mi (49.4%) Cardiology training programs: 30 (15.6%) Population: 76,657,000 inhab. (23.7%) InCanada, there are 15 cardiology Residency Programs. A total of 58newresidents (PGY-4, postgraduate year four in theCanadian numerical scheme) started their training in Adult cardiology in the 2016/2017 period (0.16 new residents/100,000 inhabitants), most of them (50 residents) receiving regular government funding (Figure 2). Most of the programs are held in the provinces of Ontario (21 new cardiology residents within five programs), and Quebec (16 new cardiology residents within four programs), especially in the cities of Toronto and Montreal, respectively. Canada is a large country territory‑wise, but with the vast majority of its 35 million inhabitants living within 100 miles of the USA border. 31,32 Brazil also has significant variability in population density and financial resources across the country and, consequently, the distribution of the residency programs is very unequal, and most of the programs are held in institutions of the South and the Southeast regions (Figure 1). In fact, a single State out of the total 26, the São Paulo State, supports more than one-third of all available positions in the whole country. This reflects the distribution of the medical schools in these areas; the Southeast region concentrates most of the medical schools, while the North region, occupied mainly by the Amazon rainforest and with the smallest population density in the country, exhibits the smallest number of medical schools and cardiology Residency programs. In the USA, the distribution of the Residency Programs in cardiology is also unequal, but not like Brazil. Despite having the smallest geographical area, the US Northeast region houses the majority of positions, and the New York State alone concentrates approximately one‑eighth of them all. 27 Creating more training programs and facilities in more distant locations in Brazil could help improve cardiovascular care in the inner regions of the country. Local authorities have been working on this issue during the past years, but with limited success. Board certification Each country has a method to certify that a doctor is legally recognized as a specialist in a field. In the USA, the American Board of Internal Medicine is the agency responsible for offering physicians the certification in cardiovascular care. In Europe, each nation has its own agency, such as the Joint Royal Colleges of Physicians Training Board in the United Kingdom and the “College National des Enseignants de Cardiologie” in France. To date, there is not a single, unified European examination valid for all countries, although some initiatives have been proposed. In Brazil, after finishing the residency, the doctor is automatically certified by the CNRM and Federal Council of Medicine as a Cardiologist. Additionally, to be certified as a Cardiologist by the Brazilian Medical Association, the physician must apply for the BSC exam, which consists of a written examination, applied once a year, during the BSC National Congress. If approved, this professional will be certified by the BSC, Brazilian Medical Association and by the Federal Council of Medicine. In Brazil, besides the residency programs supervised by the CNRM, there are 20 programs, accredited and supervised by the BSC (not by the CNRM) throughout the country. c In general, the core curriculum is similar to the CNRM programs, 20 but some differences should be noted: 1) in the BSC training programs no salary is paid to the trainee and 2) no automatic certification is granted by the Federal Council of Medicine; the trainees must undergo the BSC Board Certification test in order to be certified as a Cardiologist. Final comments The model of the medical residency programs reflects the socioeconomic conditions, and the organization of the educational and health systems of each country. A limitation of 771