Today, the medical degree certificate only gives new graduates a permit to continue studying and improving themselves, since it is impossible, over the six years of the course, to present students with the vast amounts of material that make up the various medical specialties.

This completion of training is done in a variety of ways and by a variety of institutions. Initially, there is residency, which in our specialty is well structured and controlled, although it is accessible to ever more insufficient numbers of new medical graduates. After this phase, further improvement of physicians is offered by a diversity of institutions.

The diversity and importance of these institutions is what concerns us.

Brazilian physicians prefer to update their knowledge through classes and presentations rather than through reading. Because congresses are meeting places where information is disseminated rapidly, they reach Brazilian physicians more directly. Physicians in this country work long hours and yet have good recreational options provided by our climate, which is pleasant in most of the country. Few hours remain for reading.

Universities, which have the premise of teaching and continuing to teach, are still the main source of improvement courses, provided formally through postgraduate courses, or informally through extension courses. The limiting aspect of information coming from universities is the difficulty represented by excessive formality.

Medical societies offer accessible courses and congresses in a variety of locations, in which continuing medical education is the main tonic.

These courses are generally one of the few opportunities for physicians to improve their knowledge. Therefore, they should be organized with the highest level of seriousness, since what may be said at these events will be taken to be the law by many of the participants for a long time.

It is far from rare to see invitations given to professors who meet political criteria, which ask them to make presentations on topics in relation to which they have no experience. They are invited because they are individuals of political importance, whatever this importance might be.

Colleagues who reach the level of having political importance are generally major specialists who have become prominent in their field of activity. They may act as coordinators or even as assistants in organizing the thematic program of the course or congress, but not as the presenters of topics for which new researchers may be available. Competition among the more experienced individuals may occur in several manners, but not necessarily in presentation of topics. It becomes necessary to create a hierarchy of participation in courses that will generate importance and respect for all levels of activity. This can be seen in international congresses, in the form of young presenters and experienced commentators.

Today, the major hospitals have teaching and research centers, since they understand that medical teaching and research are an important differential factor for the institutions. These hospitals have dedicated themselves to organizing updating and improvement courses, but they have the important bias of the excessive prestige conferred on physicians within the clinical staff. Belonging to the clinical staff of a hospital does not signify an ability to teach, since the inclusion criteria are based on different principles.

One novelty within the field of continuing medical education relates to the companies that sell surgical materials. It has now become possible to have an entire congress or course program through their sponsorship. Today, sensing that continuing medical education is highly attractive for physicians, these companies are starting to organize courses and updating programs using their own materials.

We need to be grateful to these companies, because without their participation, we would never have seen evolution in our courses and congresses. Their participation has also enabled access to up-to-date surgical materials. However, we need to be attentive in relation to their courses, in order to avoid distortions tending exclusively towards marketing campaigns. How can this be done? By participating in their course and imposing the ethical standards that they have always had in their relationships with physicians when they have sponsored the organization of congresses.

Journals and now Internet access for bibliographic research are an ever greater source for updating, which perhaps also ought to be modernized so as to provide well-structured abstracts in addition to the academically necessary complete texts, which would facilitate consultations. One problem that affects journals is the delay in publishing studies, which sometimes turns an extremely up-to-date topic into something that is out-of-date. Today, the RBO now allows access to studies that have been approved for publication before they are issued in the printed version. They are published in Science Direct (http://www.sciencedirect.com/science/journal/aip/01023616). Through this tool, our authors' studies are made available soon after approval by the editorial board and our readers can have access to these topics in a much shorter time.

The quantity of medical education programs perhaps requires greater control from SBOT, which could grade these courses, in the same way as done with hotels or hospitals. These grades could serve to allow physicians to prove their degree of updating, when necessary.

Having several sources of continuing medical education is an agreeable problem for us to deal with, but it needs to have special attention.

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