Professor Seabra-Gomes is the Council for Cardiology Practice’s former delegate within the Portuguese Society of Cardiology.
Cardiology in Portugal: from its origins to present day
It is difficult to confirm, from old records, when Cardiology, as a speciality, started to be practised in Portugal. In the 1940s, the different specialties started to be separated from Internal Medicine, but at that time, Cardiology was practically inexistent. Nevertheless, the Portuguese Society of Cardiology was founded in 1949 and the first department of Cardiology was created in 1959, before the existence of any University Hospital in Portugal.
In the 1950s, Cardiology started to be considered by the Portuguese Medical Association, initially through the creation of a commission to encourage existent physicians with an interest in cardiology to enter into Cardiology by consensus. The first examination in Cardiology by the Portuguese Medical Association was done in 1957 which afterwards created a Cardiology Speciality College.
Of course, before 1960 there were doctors practicing some sort of private cardiology in their private consulting rooms or at patient´s home. What could be done at that time was very little in terms of clinical diagnosis and medical treatment.
In the meantime, there was a document that changed the way medicine was seen in Portugal in 1961 - (Medical Carers Report). It defined how Cardiology should be integrated into an organised state-based-system, in public hospitals. It is interesting to remember that the Portuguese National Health Service (roughly based on the English system) was only created in 1979, four years after the revolution that ended the dictatorship system in Portugal.
Between 1960 and 1970 the principles of liberal medicine were dominant, protected by the State and coded by the statute of the Portuguese Medical Association. Afterwards, a clash began between liberal medicine and organised / collective medicine as practiced in hospitals. The patient always preferred the most renowned doctors, to most of the hospitals. The problem was that those doctors were concentrated in more urban centres of coastal areas and in the wealthiest cities. It was logical that public organisation could not construct a system of clinical services based on private practice only for some, and not make them available to the general population. However, in contradiction, it was said that "clinical private practice was the base of organised medicine". Private practice would be always defended by the patients and also by the doctors, who recognised that it is the most human form of clinical practice.
Later the aim was to establish harmony between the distribution of more expensive and efficacious clinical services at an affordable price, to an increased number of poor patients, giving patients and doctors more freedom. This discussion applies to the period when Cardiology was basically a pure clinical speciality (listening to a patient´s history, auscultation, and clinical examination, with very little help from other diagnostic tests like electrocardiography, phonocardiography and later echocardiography, etc.).
However Cardiology has grown enormously as a speciality in the last fifty years. Both diagnostic methods and medical or surgical treatments have changed and grown so dramatically that the concept of clinical private practice had to follow this evolution.
Nowadays, to become Cardiologists, doctors have to enter the Hospital Career for five years or have to have the minimum of three years of voluntary training, in both cases followed by an examination at the Portuguese Medical Association.
A problem for Cardiology in Portuguese Hospitals was the salary the hospital paid, even with over-time to cover night duties. In hospitals the work time is 35 hours a week, but during afternoons there is very little work due to a lack of hospital organisation (no consultations, no diagnostic tests, etc.). The salaries were low (one of the lowest in Europe) which was seen by doctors as an incentive to have, to maintain or to create, private consulting rooms, somehow accepting the competition or complementation between private and public clinical practice. Even nowadays, all senior cardiologists have their own private offices (alone or in groups). Contrary to many countries, Private Practice has never been allowed in public hospitals.
In Private Clinical Practice outside hospitals, it was possible to do electrocardiograms, echocardiograms (Doppler, trans-esophageal or stress), Holter monitoring, exercise tests and in some places myocardial scintigraphies). Echocardiography is the most widespread cardiac diagnostic test performed in private practice.
The system worked as such until two things occurred.
First was the appearance of insurance companies contracting services they provide: any type of diagnostic tests, surgery or angioplasties. Payment for consultation was ridiculously high which forced some doctors to accept the contracts. Somehow, private practice continues, but doctors had to accept that the patient preferred tests and treatments over doctors and the doctor-patient relationship.
The second was the appearance of private hospitals. Their aim is clearly to make a profit and they openly admit to such. They are proving that Health is a good business. Private hospitals have contracts with all insurance companies, and accept doctors only because they still need them. Payment to doctors is even lower then directly through the insurance companies. It is not surprising that in the near future and in some areas, doctors will be replaced by technicians (cheaper for CT Scans and Magnetic Resonances).
In the meantime, because there is an excess of doctors in public hospitals, Cardiologists are attracted to working in private hospitals from the beginning of their careers. Departments of Cardiology are being created in these private hospitals but these doctors rarely work exclusively in private practice. Recently it was announced that In the near future private hospitals (at the moment there are only 3 in Lisbon) will have their own private medical schools.
The "independent cardiologist" as we find in other countries such as the USA, is certainly in decline! It continues to have the greatest value because nothing can replace the human nature of the doctor-patient relationship. When a patient goes to a public or private hospital, the relationship is between patient and hospital, but not with the doctor. Unfortunately, doctors alone cannot provide CT scans or magnetic resonances.
Professor Rafael Ferreira describes below the training of cardiologists in Portugal, continuous medical education (CME) and clinical practice in his country.
Training of Specialists
Portuguese cardiologists accomplish a Hospital Internship of Cardiology at the hospitals of the National Health Service (NHS). Annual admission to the internship is made through a public application, the number of vacancies being previously defined by the Health Department. The internship can only take place in those Departments of Cardiology classified as “Apt for specialist training” by the College of Cardiology of the Portuguese Medical Association (PMA).
The internship consists of one year of internal medicine and four years in cardiology that includes:
- Clinical cardiology (hospital ward, general emergency and outpatients)
- Intensive cardiac care
- Non-invasive techniques: electrocardiography (conventional, stress-ECG and
- Holter recordings), echocardiography and Doppler, nuclear cardiology and MRI
- (optional) Invasive techniques: hemodynamic and interventional cardiology
- Cardiac pacing and electrophysiology
- Training in paediatric cardiology
- Cardiac surgery.
A final examination, both theoretical and practical, completes the internship and awards the title of cardiologist acknowledged by both the Health Department and the PMA.
Continuous Medical Education
Continuous education at an official level is defined by the Hospital Career. Certified cardiologists apply for a 5-year position as “Hospital Assistant”. At the end of the 5-year period their performance is evaluated by an examination which, if passed, allows them to become "Consultants in Cardiology". The exam values the clinical activity developed along the period, but special relevance is given to clinical investigation and published articles. After five years of fulfilment as a Consultant, the cardiologist can apply for the position of “Head of Department”, the highest position in the hospital career.
In Portugal physicians are not obliged to obtain recertification since it is taken as granted that such a desideratum is accomplished throughout the hospital career which includes almost all registered Portuguese cardiologists.
The Portuguese Society of Cardiology (PSC) plays an important role in the continuous education of cardiologists. There are almost 800 cardiologists registered in the College of Cardiology of the PMA (which is mandatory) and around 700 of these are members of the PSC. Nurses and Technicians may also be accepted as aggregated members and there are about 200. The annual congress of the PSC assembles more than 2,000 health professionals and it is a unique opportunity for an update on the main themes of clinical cardiology as well as for presentation of the original investigations in the field of cardiology including basic research. PSC has, on the other hand, one association (APAP - Portuguese Association of Arrhythmia and Pacing) and 16 working groups and nuclei that organize meetings on different topics in their own area of interest throughout the year.
Clinical Practice in Cardiology
Cardiology practice as far as it concerns hospital admission, intensive cardiac care, invasive techniques and cardiac surgery is almost entirely performed in Public Hospitals. Recently some private institutions have begun to develop a network of hospitals in the main centres – Lisbon and Oporto – with a large capacity in the field of invasive examinations.Out-patient cardiology and non-invasive tests have a relevant ambulatory component. The NHS has agreements with various private institutions and physicians to perform non-invasive tests in private offices and clinics. The quality of the tests is under the control of the College of Cardiology of the PMA.
Data on cardiology practice in Portugal (2007) can be found hereafter:
Interventional Cardiology is performed in 19 hospitals of the NHS. A specific competence in this technique is given by the College of Cardiology of the PMA after intensive training in reference centres. The number of procedures in 2007 was 10,500 (primary angioplasties numbered 1,900). The total number of catheter examinations in these centres was about 26,600.
Adult Cardiac Surgery
Adult Cardiac Surgery is performed in eight Cardiac Surgery Departments in the country. The number of coronary surgeries decreased from 2,730 in 2004 to 2,390 in 2007; in the same period the number of isolated valve surgeries increased from 1,600 to 2,100. As far as the combined surgery is concerned the number of procedures increased from 475 to 600. Paediatric cardiac surgery is performed in five centres in the main University Hospitals. In Lisbon the Red Cross Hospital also has a good performance in this area. The total number of procedures increased from 560 in 2004 to 690 in 2007.
There are 4 centres of cardiac transplant in the main university centres. Coimbra is now the most active one with more than half the total of the 45 transplants performed in 2007.
There are more than 40 institutions in which pacing is a routine technique. This means four centres per million population. In 2007 there were 7,632 procedures – 80% were first generator implantations and about 20% were battery replacements. There was a significant increase in physiological pacemakers. Isolated atrial stimulation systems still account for only a few implantations. VDD systems with a single electrocatheter are increasingly used. Mention should also be made of the increase in the use of rate responsive pacemakers ( AAIR/VVIR/VDDR/DDDR).
Invasive Electrophysiology (data from 2006)
There are 19 centres in Portugal (15 in public hospitals and four in private institutions). Operators in this technique have a specific competence given by the College of Cardiology of the PMA after intensive training in reference centres. The total of EPS was 1,805, and 75% of the patients were submitted to ablation therapy. 738 ICDs were implanted – 230 (34%) together with resynchronization systems. This means 67.4 ICDs per one million inhabitants, a number which is considered low according to European standards. 12 centres implanted more than 10 ICDs a year. Only five centres fulfil the criteria to be a training centre.