Both DCNs preserve the minimum workload of 7,200 h over at least 6 years (2, 3). The internship remains a central component, corresponding to a minimum of 35% of the total workload, and a duration of 2 years. However, the 2025 update elevates its prominence.

The new DCNs reaffirm the requirement for strong integration of the internship with the SUS, introduce more detailed specifications for clinical rotations, and mandate systematic monitoring of student performance. In addition, they standardize and reduce the theoretical component of each rotation to 5%–15% of total hours. Didactic time should focus on case discussion, evidence-based updating, and supervised consolidation of content essential for safe, supervised clinical practice.

The 2025 DCNs maintain the requirement that at least 30% of internship hours be distributed proportionally between Family and Community Medicine and Emergency/Urgent Care is maintained, rather than equally. The remaining 70% must, in a transversal and integrated manner, encompass Internal Medicine, Surgery, Obstetrics and Gynecology, Pediatrics, and Mental Health, with the explicit inclusion of Public Health, Intensive Care, and Trauma/Orthopedics (3). The 2014 DCNs also orients practical training toward national epidemiological priorities and explicitly incorporates palliative care across the life course.

Another significant improvement concerns the sites where internships may be carried out. The possibility of completing up to 25% of the workload in external institutions was maintained, but exceptions allowing higher percentages with institutional authorization were eliminated. From 2025 onward, eligible external institutions must preferably be linked to SUS, offer medical residency programs accredited by the National Commission for Medical Residency (CNRM) (26), and comply with standards of quality, infrastructure, and safety. Additionally, the new guidelines strengthen the role of the home institution, requiring that its faculty remain actively involved in student supervision even when training occurs in affiliated sites. Together, these changes introduce stricter regulatory standards from 2025 onward, eliminating prior flexibility and establishing a national standard for supervision and quality.

Regarding supervision and preceptorship, both versions acknowledge the importance of service-based teaching in the health system under faculty guidance. The 2025 version, however, advances substantially by instituting continuous pedagogical training programs for preceptors within the health system and by institutionalizing Centers for Pedagogical Support and Faculty Experience (NAPED, Núcleos de Apoio Pedagógico e Experiência Docente, structured as institutional centers responsible for faculty development), or equivalent structures, as formal mechanisms for faculty formation and development. The explicit aim is to foster ongoing professional education focused on the pedagogical competencies essential to the “new profile” of physicians.

In practice, from 2025 onward, the internship becomes more standardized, rigorous, and connected to competency-based assessment, whereas in 2014 it was more flexible, descriptive, and open to local adaptation. Points of continuity preserve system integration and large-scale service learning. However, the emphasis on monitoring and standardization in 2025 marks a shift toward greater accountability for medical schools (23), while reducing curricular flexibility.

It is important to underscore the centrality of the assessment system, particularly at the transition to the medical internship. The 2025 Guidelines require at least one comprehensive summative assessment to ensure that students demonstrate the minimum competencies needed for safe, supervised performance in real clinical settings. This measure strengthens institutional accountability and ensures greater uniformity in verifying professional readiness prior to supervised clinical practice.

The 2014 DCNs formally established a biennial, mandatory national evaluation of medical students, coordinated by INEP (25), designed to be formative and contextual. The results were expected to contribute to the quality assurance of undergraduate programs and could be considered as part of the residency admission process, although its full implementation was never consolidated.

Additionally, the 2014 DCNs established a competency-based curriculum centered on the formation of generalist, humanistic, critical, and reflective physicians, organized into three integrated domains: Health Care, Health Management, and Health Education. This structure promoted early and longitudinal immersion in health services, in addition to the transversal use of information and communication technologies (ICTs) and the requirement to master at least one foreign language (2).

The 2025 DCNs preserve the tripartite structure of medical training, while significantly expanding it by incorporating competencies for the digital era. These include mastery of technological tools such as artificial intelligence (AI), telemedicine, minimally invasive procedures, machine-learning algorithms, large-scale data analytics (Big Data), and artificial neural networks, applied to diagnosis, clinical decision-making, and health management.

In addition, the guidelines mandate compliance with the principles and provisions of Brazil’s General Data Protection Law (LGPD) and related regulations. They require the protection of personal data and the ethical use of information. Security, confidentiality, and integrity must be ensured for personal and sensitive data of patients, professionals, and institutions across all contexts of medical practice.

The new guidelines also incorporate transversal competencies related to sustainability and to action in public-health emergencies and natural or anthropogenic disasters. In these contexts, graduates must demonstrate proficiency in biosafety, health surveillance, risk management, and rapid crisis response, including pandemics, large-scale accidents, and extreme weather events. Moreover, future physicians are expected to understand the social, environmental, and epidemiological impacts of climate change. They should also connect these dimensions to wellbeing, diversity, and a sense of belonging in professional practice.

The 2025 DCNs further reinforce the profession’s commitment to human rights, equity, and diversity, orienting graduates to recognize and value the multiple dimensions of the human condition. It is important to highlight that the guidelines explicitly name the populations historically marginalized within the Brazilian healthcare system. This deliberate act is politically significant because it affirms visibility and strengthens social accountability. The DCNs hallmark the physician’s social responsibility to practice with respect for biological, cultural, ethno-racial, gender, sexual-orientation, and belief diversity, ensuring ethical, inclusive, and humane care, especially for vulnerable or historically neglected populations. These populations include Indigenous peoples; Black communities; Quilombola communities (Afro-Brazilian communities descended from people who established settlements after escaping slavery in Brazil); riverside, rural, and forest populations; people experiencing homelessness; LGBTQIAPN + individuals; people with disabilities; people deprived of liberty; migrants, refugees, and stateless persons, among others. By restoring the full enumeration present in the regulatory text, the guidelines underscore that equity-oriented medical training must be guided by the needs and lived realities of these communities.

The guidelines reaffirm the indissociable integration of teaching, research, and extension, encouraging early scientific engagement and social immersion as part of the graduate profile. Overall, the profile becomes more closely aligned with the demands of the 21st century, incorporating environmental, digital, and psychosocial dimensions and making explicit new expectations: person/family/community-centered care; equity and social justice; collaborative leadership; ethical action in the face of 21st-century sanitary, environmental, and digital challenges; and the critical integration of clinical, scientific, and technological knowledge. Finally, the guidelines underscore an active commitment to the strengthening of the SUS.

The 2025 DCNs reinforce the indissociability of teaching, research, and extension, explicitly promoting early scientific initiation and structured participation in community-based extension projects as formative components of the graduate profile. These initiatives aim to strengthen social accountability and stimulate lifelong learning.

To ensure effective implementation of the goals defined in the 2025 DCNs, medical schools should adopt an integrated set of institutional structures, policies, and practices. These include: a pedagogical support and institutional centers responsible for faculty development (NAPED, or equivalent) as a permanent locus for faculty and preceptor development; an Institutional Center for Inclusion and Belonging responsible for fostering an equitable, welcoming, and diversity-representative educational environment; an Institutional Programmatic Assessment System; an Institutional Student Support and Monitoring Program; a Policy for the Promotion of Student Health and Well-Being; and learning and simulation environments aligned with patient safety and curricular outcomes. While such structures provide a coherent foundation for high-quality medical education, they may pose implementation challenges for institutions with limited infrastructure (5).

The 2014 DCNs already emphasized integrated assessment processes and provided for a national biennial evaluation coordinated by INEP. However, assessment remained descriptive and locally defined, without a formal programmatic model applied across all curricular components (27). By contrast, the 2025 DCNs transform this paradigm by requiring an institutionalized, continuous, and comprehensive system of assessment, explicitly grounded in the principles of programmatic assessment and encompassing both theoretical and practical components, including the internship. Key indicators and alignment items are summarized in Supplementary Table 1.

As previously detailed, the programmatic assessment (27) integrates multiple sources of evidence on student performance in a longitudinal, competency-oriented model that supports meaningful learning and professional development. The 2025 DCNs consolidate this approach as a national standard for readiness verification. Implementing this methodology requires that medical schools organize an articulated set of tools and occasions, such as workplace-based assessments, objective structured clinical examinations (OSCEs), reflective portfolios, structured feedback, multisource (360°) feedback, and progress tests. Each strategy has limited value in isolation; when integrated within a coherent system, however, they provide a comprehensive view of the learner’s trajectory, increasing the validity and reliability of educational decisions.

To that end, the presence of progression committees (or student monitoring boards) is indispensable. These bodies analyze the aggregate dataset and issue integrated, defensible judgments about the development of competencies defined in the graduate profile. The institutional challenge is to consolidate a system that values competence-based progression, shared pedagogical responsibility, and stewardship of the learner’s developmental pathway.

In addition, the 2025 DCNs require each medical school to implement a comprehensive summative examination immediately before the start of the internship, accompanied by structured feedback and individual action plans in cases of unsatisfactory performance. While the guidelines establish the obligation of a pre-internship readiness assessment, they do not prescribe a national, standardized, or centrally coordinated examination model. The design, scope, and operationalization of this summative exam remain under institutional responsibility. This model points towards more rigorous institutional accountability for medical schools (23) while reducing some aspects of curricular flexibility. Internship assessments likewise undergo substantial change: whereas the 2014 DCNs left the structure of internship evaluation largely to local discretion, the 2025 DCNs strengthen expectations for programmatic assessment and more uniform institutional governance of internship outcomes, without establishing a nationally standardized system.

Student performance must be monitored continuously and linked to the results of the pre-internship summative exam. This ensures that progression is based on objective evidence of competence. In this context, the National Examination for the Evaluation of Medical Training (ENAMED) (6), applied in the 4th and 6th years, has emerged as a federal initiative aimed to support and strengthen programmatic assessment nationwide.

Established in 2025, ENAMED is an annual national exam that evaluates the quality of medical training and holds institutions accountable for students’ academic performance. However, it is not mandated by the 2025 DCNs, which require each school to implement its own programmatic assessment and at least one comprehensive summative exam before the internship (3), without explicitly referring to ENAMED.

In this sense, ENAMED functions as a complementary mechanism that can strengthen institutional evaluation systems. It helps monitor learning progress, identify formative gaps, and verify readiness for supervised practice (5, 6). This reform elevates the internship from a predominantly formative experience to an essential certification milestone. It seeks to consolidate a system-level approach to readiness verification while preserving local curricular identity within national parameters (3, 5, 28–30).

The 2014 DCNs recognized protected and simulated environments as relevant strategies for teaching and for error analysis; however, they did not require medical schools to maintain dedicated skills or simulation laboratories.

By contrast, the 2025 DCNs make these spaces mandatory, defining them as structured learning environments designed to prepare students for clinical practice with explicit emphasis on patient safety, standardized skill acquisition, and supervised procedural training. Operational elements mapped across both DCNs appear in Supplementary Table 1.

Within these environments, students can err, reflect, and improve without risk to patients, reaffirming that learning safety is inseparable from patient safety. In addition, such spaces must be integrated into assessment and research systems, serving as controlled settings for performance measurement and structured feedback. In this way, infrastructure ceases to be merely physical support and becomes a strategic pedagogical device.

This requirement aligns Brazilian medical training with international standards of safety and quality, recognizing simulation as an essential pedagogical resource for harm prevention and for the progressive development of clinical and communication competencies.

At the same time, the guidelines reaffirm that supervised clinical practice in real healthcare settings remains the irreplaceable core of medical training. Simulation is framed as a complementary strategy that enhances learning safety and supports the gradual acquisition of technical and non-technical skills, but not as a substitute for authentic patient-care experiences within the SUS. The DCNs also clarify that effective simulation does not depend on high-technology or highly aseptic facilities, which may distance students from real-world clinical constraints. Instead, they emphasize low-cost, context-appropriate models grounded in functional fidelity, in which the cognitive, procedural, and decision-making demands of the task outweigh the sophistication of the equipment.

In 2014, the DCNs merely mentioned ICTs and foreign language proficiency as transversal requirements. In 2025, the text explicitly incorporates AI, telemedicine, machine learning, big data, and the ethics of digital platforms, as well as the protection of confidentiality and personal data in accordance with Brazil’s General Data Protection Law (LGPD) (31). These elements are integrated with evidence-based practice, interprofessional teamwork, and leadership. This update positions Brazilian medical training in direct dialogue with digital transformation and global standards. It aligns with the NHS Topol Review and the WHO outcomes framework, both of which call for digitally literate clinicians capable of working safely in modern information ecosystems (12, 13). The incorporation of digital competencies presupposes the availability of human, technological, and pedagogical resources that remain unevenly distributed across Brazilian schools, requiring phased implementation strategies and institutional centers responsible for faculty development (NAPED). A consolidated comparison of digital-competence requirements is provided in Supplementary Table 1.

The 2014 DCNs emphasized diversity, human rights, and ethical formation, but it did not establish formal policies or structures for student support. By contrast, the 2025 update institutionalizes “green areas” within the standard week, protected time reserved for self-care, research and extension activities, mentoring, and electives (32). It also requires each medical school to implement an institutional program for student support, establish centers for inclusion and belonging, and maintain formal mentoring programs for academic and personal guidance (3). Structural requirements and monitoring suggestions are outlined in Supplementary Table 1.

However, while the 2025 DCNs advance institutional support mechanisms, the broader structural determinants of distress in Brazilian medical training still permeates learning environments. Medical work is still characterized by long hours, productivity pressures and chronic clinical overload, factors consistently associated with high levels of stress, emotional exhaustion and burnout among physicians in Brazil (33, 34). These pressures foster patterns of constant availability, accelerated performance, and early socialization into a culture that normalizes exhaustion. Students are similarly affected, showing marked increases in stress and fatigue during evaluation periods (35, 36) and a persistently high prevalence of common mental disorders linked to intensive workload and institutional pressures even outside crisis contexts (37). Recent analyses of Brazilian medical education further demonstrate how service-centered organizational cultures, workforce shortages, and productivity-driven expectations shape teaching practices and influence both faculty wellbeing and student experience (38).

In parallel, the 2025 DCNs recognizes the importance of inclusive educational environments for historically underrepresented and vulnerable student populations, such as Black, Indigenous, and quilombola students, LGBTQIAPN + individuals, persons with disabilities, and others, through institutional programs for inclusion and belonging. These measures align with national policies for diversity and equity in higher education. The guidelines also extend inclusion to neurodiverse students, promoting accessibility and support mechanisms across the curriculum.

Collectively, the transformations observed in the 2025 DCNs not only reshape the internal dynamics of medical education but also align Brazil’s framework with global competency-based movements that emphasize holistic formation and social accountability. Table 2 presents the alignment of the 2025 DCNs with international frameworks and emerging trends, highlighting convergences with global standards and the distinctive features of the Brazilian context.

Brazil’s 2025 DCNs can be interpreted as a maturation of CBME, less concerned with enumerating content and more focused on ensuring readiness, safeguarding patients, and caring for learners. The move to a system-wide programmatic assessment, coupled with a comprehensive pre-internship summative exam and mandatory feedback with action plans, brings Brazil closer to the design logic found in WFME standards, GMC Outcomes, and the programmatic assessment literature (8, 9, 11, 28–30).

Although the new requirements present challenges related to faculty development and the standardization of assessment criteria, this regulatory shift nonetheless positions Brazil in alignment with global trends in competency-based medical education, consistent with standards set by WFME (8), GMC (11), AAMC EPAs (10), and CanMEDS (9). Across these frameworks, assessment is conceived as a longitudinal process that integrates formative and summative judgments, emphasizes direct observation of competencies, and uses performance data to guide feedback and remediation. In particular, the WFME (8) standards advocate for coherent, outcome-aligned systems with continuous improvement, while the GMC Outcomes (11), AAMC EPAs (10), and CanMEDS (9) roles converge in prioritizing observable competencies at critical transitions in training.

From a Global North perspective, convergence is evident around observable competence (e.g., AAMC Core EPAs), longitudinal assessment, simulation for patient safety, and digital capability (GMC, WFME, Topol) (8–13, 28–30). Where Brazil diverges is in its explicit social-accountability mandate and SUS orientation, which place health-system stewardship more centrally than in many high-income frameworks (2, 3).

A plausible explanation for these contrasts lies in health-system design and governance. Brazil’s publicly funded SUS (1) embeds legal and regulatory mandates for social accountability, equity, and primary-care orientation, which pull the DCNs toward system stewardship (workforce distribution, primary-care exposure, public-health readiness) as a central educational outcome (2, 3). By contrast, many mixed or insurance-based systems in high-income settings emphasize institutional autonomy and accreditation logics that privilege observable competence, patient-safety simulation, and digital capability while locating social accountability more variably across schools and regions) (8–13, 28–30). Differences in regulatory cadence (periodic national guideline updates versus decentralized program standards) and in quality-assurance instruments further shape how similar competency ideals translate into curricular governance, helping to explain convergence on assessment/simulation/digital skills alongside Brazil’s stronger SUS-oriented mandate (2, 3, 8–13, 28–30).

In the Global South, parallels can be drawn with India’s National Medical Commission, particularly the Attitude, Ethics, and Communication module, which explicitly links competency articulation to professional identity formation. Similarly, South Africa’s Health Professions Council (HPCSA) competencies foreground social justice, teamwork, and community responsiveness as central educational goals. Likewise, WHO’s UHC outcomes framework emphasize cross-cutting, system-ready competencies that prepare graduates to navigate complex health systems (12, 16, 17). Within this broader landscape, Brazil’s formalization of protected student time, mandatory simulation infrastructure, and comprehensive programmatic assessment, including the internship, appears comparatively forward-leaning, positioning the country as an emerging reference point for CBME reform in the Global South.

Building on the DCNs/2025 (3) regulatory shifts, we translate governance updates into day-to-day implementation in medical schools. We assume that practice-readiness rests on a longitudinal assessment system; that its credibility depends on skills/simulation infrastructure focused on safety; that effective formation today requires integrated digital competence under LGPD-aligned data governance; and that sustainable excellence hinges on institutionally owned wellbeing and inclusion with protected time and structured support. By articulating these four axes (assessment, infrastructure, digital, and learner support), we outline operational pathways for implementation and monitoring that acknowledge resource heterogeneity across institutions and the need for equity-oriented rollout (3).

Building on the earlier description of programmatic assessment, schools should implement a continuous, multi-evidence system that monitors student development and informs academic decisions (3, 8–11, 39) through structured feedback and progression committees (3, 8–11, 39).

To safeguard decision quality, the system should include a Progression Committee responsible for judging longitudinal evidence sets drawn from workplace-based assessments (WBAs), objective structured clinical examinations (OSCEs), reflective portfolios, and multisource feedback, all against explicit criteria and shared performance standards (3, 8–11, 39). In addition, the 2025 DCNs stipulate a pre-internship summative examination accompanied by formal remediation plans to certify readiness for supervised practice; this capstone aligns institutional judgments with national performance criteria and strengthens the transparency, equity, and credibility of the overall assessment process (3, 8–11, 39).

Schools should ensure the implementation of skills and clinical simulation laboratories that progressively integrate technical–procedural training with scenario-based, interprofessional simulations, in alignment with the competencies specified in the curriculum. These environments must operate with safety checklists, structured briefing and debriefing protocols, case libraries mapped to learning outcomes, and ongoing faculty development plans focused on facilitation, scenario conduction, and reflective analysis of simulated practice.

In the 2025 DCNs, simulation is recognized not merely as a teaching method but as a patient-safety intervention that must generate objective evidence of performance and trustworthy assessment data. Systematic records from debriefing sessions should be incorporated into the programmatic assessment system, thereby strengthening feedback loops in the training process, standardizing learning opportunities, and reinforcing an institutional culture of quality and safety (3, 8).

At the same time, although the 2025 DCNs incorporate sustainability and socio-environmental health, they do not explicitly delineate the competencies required for clinical and organizational action in disasters, extreme weather events, or environmental emergencies, domains increasingly emphasized in international medical-education frameworks (41, 42). Given the country’s socio-environmental vulnerabilities and the rising frequency of climate-related crises documented globally (43), simulation laboratories represent an optimal pathway for developing disaster-medicine competencies. Scenario-based simulations involving mass-casualty incidents, floods, heat-related emergencies, or service disruptions can provide structured, safe environments for students to practice crisis decision-making, teamwork, triage, and communication, skills essential for contemporary medical practice in a changing climate.

Institutionalizing protected time within the curriculum, dedicated to self-care, research and extension activities, academic mentoring, and guided remediation, requires transparent eligibility criteria and systematic monitoring of utilization and equity across student groups. These intervals should be formally embedded as structural components of the pedagogical project, rather than optional periods, to promote mental health, academic engagement, and the sustainability of learning.

To ensure effectiveness and distributive justice, the school should operate tracking dashboards and simple indicators capable of detecting underuse or unequal access and, from there, activate institutional support responses (tutoring, counseling, workload adjustments, research opportunities). By linking student wellbeing policies to concrete educational outcomes, “green areas” consolidate the school’s commitment to the integral and humanized formation of future physicians (3, 32).

Establishing and implementing an Institutional Center for Inclusion and Belonging within a medical school is a strategic, structuring action to consolidate an academic culture that is more equitable, welcoming, and representative of human diversity. More than a physical space, the center should function as a pedagogical and relational device capable of mobilizing people, fostering critical reflection, and inducing institutional practices that translate, into everyday academic life, the principles of equity, social justice, and respect for difference.

The center’s mission is to coordinate and articulate institutional policies on inclusion and diversity with emphasis on ethno-racial, cultural, social, gender, and sexual-orientation dimensions, while developing permanent programs for awareness, training, and response to discrimination. At the same time, it should ensure psychosocial welcome, qualified listening, and support for students in situations of vulnerability, acting as a bridge between individual care and institutional transformation.

To make this mission operational, the center must adopt clear governance, maintain dashboards that monitor access, progression, and organizational climate, and provide rapid-response supports (academic, psychosocial, and financial), triggered by early indicators derived from assessment data. These mechanisms should be accompanied by the publication of annual reports to secure transparency, institutional learning, and continuous improvement. By institutionalizing these functions, the Center for Inclusion and Belonging render the medical school’s social accountability tangible and strengthens the retention and success of diverse students (3, 8, 19, 20).

The 2025 DCNs consolidate digital literacy as one of the structuring pillars of medical training, integrating content on artificial intelligence (AI), telemedicine, machine learning, and big-data analytics into clinical cases, supervised clerkships, and health-innovation projects.

Beyond technical proficiency, the guidelines emphasize ethics and data governance in compliance with Brazil’s General Data Protection Law (LGPD), ensuring responsible, secure, and transparent use of information across all educational and care processes. Accordingly, teaching should explicitly address informed consent, data minimization and security, auditability, and responsible reuse, so that e-portfolios, simulation records, and learning-analytics systems function as trustworthy and ethical sources for educational and clinical decision-making (3, 8, 11–13).

This shift requires the Curricular/Program Committee (NDE) to adopt a new mindset toward curricular review, integration of digital technologies into the learning process, and the cultivation of a pedagogical culture capable of preparing physicians to act with competence, critical judgment, and responsibility in the era of digital transformation in health.

To professionalize teaching, feedback, bias mitigation, and competence in simulation and assessment, schools should implement NAPED (or an equivalent) as a permanent faculty-development structure. This program must include SUS preceptors, strengthening the education–service interface and ensuring competency-based, ethically grounded, and socially accountable training with clear feedback standards across practice settings.

Faculty development should be modular, continuous, and anchored in real practice artifacts, such as rubrics, debriefing notes, and feedback excerpts, to drive consistent and measurable change (3, 8). In this perspective, NAPED or its institutional equivalent stands as a pillar of academic governance, indispensable for sustaining the implementation of the 2025 DCNs and for consolidating a faculty culture oriented toward quality, equity, and innovation in medical education.

Governance of clinical rotations requires standardizing rotation portfolios to ensure compliance with the ≥35% internship requirement and with the mandated exposure to Primary Care and Emergency within the SUS. Local assessments should be aligned with the pre-internship capstone and the programmatic assessment framework, so that judgments at transition points are coherent across training sites.

To sustain comparability, programs should use shared rubrics, set targets for workplace-based assessment coverage, and hold periodic calibration meetings across teams and practice settings, thereby maintaining reliability of results across rotations (2, 3).