He warned me in the middle of the conversation that he intended to work until he was 90 years old. It was during the National Access Examination (PNA), held in 2019, that he thought that this would be the moment of the final decision of his career. He wanted to choose Rehabilitation, but the PNA did not go as he expected and he ended up choosing General and Family Medicine. Sometimes, the paths that seem to narrow are the right ones to get us to where we never thought we would be.
Working until the age of 90, this was the phrase that most impressed me in everything he said. The longevity of life and his personal ambitions are his absolute conviction, with no room for breakdowns or fears. There is, however, something curious about him, what he understands today to be his path, may change in the near future. "Volatile?", I ask him. No, just free to accept that a conviction, or a goal, does not have to be the same forever, a characteristic that he attributes to people who are similar to him, and, like him, rational.
There is much to say about him, even though he is only 25 years old, completed on 23 December. He says that receiving gifts was never a problem, but parties with school friends were the most sacrificed. As he always believes that the bottle is still half full, it was the prolonged holidays he liked to experience, with no regrets.
Afonso Schönenberger Braz is in the first year of his internship in General and Family Medicine, at the São João do Estoril USF (Family Health Unit).
The Schönenberger surname confers him dual Swiss nationality, inherited from his maternal grandmother who, although no longer living there, maintains her family and roots there. As for the Braz surname, on the other hand, he inherited it from his father and from the Ribatejo link, specifically Santarém, the land where he was born and lived until he came to Lisbon to study medicine. From Switzerland, he remembers the lullabies sung by his mother when he and his other two brothers were small. Now he keeps only small habits, like having cheese fondue when the whole family gets together. As for German, he learned it in a hurry, while he was at the Faculty and through the Students' Association (AEFML), a language that he did not want to lose from his genetic code and because he needed it to study the entire year 4 of the Medical Degree in Munich. Did he already have a good command of German to study medicine for an entire year? No, not at all. It was this language barrier that let him down in the early days, when he realised that he did not understand anything in class. Thanks to a lot of effort, study and coffee, he was successful in the second semester, doing everything that was required of him. This was his great emancipation moment, today he knows that he will be able to live anywhere in the world.
At the age of 17, he was not prepared for professional choices, but Medicine was not a random decision, in fact the genetic code was there once again. His mother is a hospital pharmacist and his maternal grandfather is a paediatrician. He would even consider embracing other passions such as management/economics, or history, a passion also shared by his father.
As he grew up, his curiosity for other experiences increased. He was a scout and practiced water polo, but an injury in his knee and Achilles tendon stopped him and showed him the weaknesses that, as a rule, are less evident. Today, when reflecting on what his “Achilles' heel” is, he says it is the fear of failing and disappointing others.
He is a mixture of an angel and a devil. Whereas the devil part constantly tells him that he will fail, the angel inspires him and tells him that fear will not stop him and that he should move on without even knowing the ground he steps on. Courage or madness? Both, but together with the self-esteem that his solid family helped him build by giving him freedom of choice, but demanding action.
He recalls academic life with a longing smile. He was a member of the AEFML and the mentor of a few younger students. He does not favour aggressive or humiliating welcome to new students, a practice that is unusual in the Faculty. In 2018, he was the general coordinator of the Medical Evening, the great moment of their academic lives that places satire on stage to expose what goes less well in teaching, “we are pointing out what is not well and what we want to change, it is an evening that makes one think”. Afonso also recalls with a big smile some of his lecturers of excellence, like Carmo Fonseca, Bruno Silva Santos, Luís Costa and Miguel Castanho, and their classes which, albeit not of mandatory attendance, were always packed.
In year 6, he combined his hospital internship with the study for the Final Access Examination. Not satisfied with the ambivalence of the challenge, he decided to go to Switzerland for a month and a half as an intern in general surgery. In his final year curricular internship in Santa Maria, he witnessed death and had close contact with life and loneliness. He told me that they were often the last to be with patients who could not say goodbye to their families.
He then started the specialty, General and Family Medicine, which will last for 4 years. As a family doctor, his audience is the most comprehensive, seeing both elderly people, new-borns, or teenagers. He will have to interpret behaviours, looks, body language, or silence, to understand what patients feel and what hurts them. A complicated task for those, especially now, who cannot even exchange communication empathetic gestures in order to better decode others.
After the specialty training, Afonso will take a final exam and only afterwards will he be able to apply to different health centres, as a specialist and with his own list of patients.
Regarding the interview scheduled in advance, we agreed that we would swap the face-to-face meeting with the digital one. We share our taste for coffee, a taste that kept him awake during the long nights spent studying for the Final Access Exam and then to study in Munich.
We wanted to know more about the path of someone who starts his internship after having completed the Integrated Master Degree in Medicine, and how a new recent graduate deals with day-to-day life, in a catastrophe scenario like the current pandemic.
You belong to the group of students who sat the Specialty Access Exam for the first time after the famous Harrison. But you already told me it didn't go well. Why was that?
Afonso Braz: I really wished I had not been part of this initial group. When they said it would be the 13/19 (start and end of the degree) to take the Exam for the first time, I didn't like it. Thankfully, this change happened, it was necessary, because now there are clinical cases, it makes us think. But different study methods were implemented for different people and some were going to be more prepared than others. It was only after this year that it was firmly known what was to be done, just before the day of the exam. Now, looking back, I would have had a different study method. The exam fell far short of my expectations and the following week I broke down completely. I had worked for a whole year and I didn't get the place I wanted.
For you, what does break down mean?
Afonso Braz: I can handle it. I don't show it. I may be in a very bad shape, but externally, in my relationship with others, nobody notices. Only my closest friends. The following week I did the final year students’ trip and then I decided it was the right time to stop drinking coffee. It didn't go well either, I had many headaches (he laughs). And now that I look back, I know that at the time we look at the exam and think “it’s either this or nothing” and we think that it defines us, that it defines our life. We, medical students, get used to perfectionism and then, when something fails, we think it is a deleterious situation. And it can't be so, because we lose self-esteem, we feel that we are not good enough, especially after so much effort, badly slept nights and nightmares. In the days before the exam I dreamed that I had failed, then the exam came and it went wrong for me. The day I realized the grade I was going to have in the exam, I woke up from a nightmare, and my thought was, "It's over, I had a bad grade, but it was just a dream". But 3 seconds later I realized that it was all real. Now I firmly affirm that life doesn't end there, it's just an exam!
Does this sense of failure come from competition, or just quest for perfection?
Afonso Braz: The competition also exists, but it is within me, it does not show. But it is only with the intention of improving myself and not having someone have less, just for me to win from it. What hurt me was my own pride, not having been good enough. And today I insist a lot on this topic because I want my colleagues, who are preparing for the exam, to know that it does not define us. If the exam doesn't go so well, then what happens? There are several ways, you can try again, go abroad and do the specialty you want so much. Nothing ends, it's just an exam. There are serious problems in life and this is not one of them.
Recently (about a month ago) you started the specialty, where you will practice General and Family Medicine. How are these new times?
Afonso Braz: I'm getting used to a new family. To my new tutor, who is great, I am part of a very dynamic team and I have been adapting calmly because the specialty is very organized. There, we are protected, encouraged to learn over time and understand how the health centre works. Growth is gradual and integrated and we learn to do well, with time. Every week we have 4 hours of training, or discussion of articles, ideas and presentations, it is very stimulating.
How have these pandemic times been in contact with patients? Are they going to the centre? Is it mostly from a distance?
Afonso Braz: At the moment, all the centres have a hybrid model, that is, many issues can be resolved by phone and email, and this is to try to protect the contact between everyone. But then there are health essential aspects that we cannot neglect, such as maternal, child and geriatric health. There is a follow-up that must be continued because there is a pandemic, people come in and are protected, just like us. But they have to come.
Is this the first real contact with patients?
Afonso Braz: I felt this great responsibility for the first time in my common year of the internship. At this stage, we already have great contact with patients and there is responsibility for what can happen to them. There are few things so gratifying in life like people thanking us for what we did for them, and there have been moments like that since the internship. There are people we cannot save, but small things that are not therapeutic, such as seeing if the person is cold and warming him up, are very important for us. We need to feel how patients are doing and General Medicine does that a lot. It is curious because now, due to masks and distance, what conventionally should be our area is distorted. There should be a very close relationship with patients and now we listen to them over the phone, read what they write, the closeness to people is lost. It is the contact that tells us something about the person. The contacts that were established before the pandemic will remain, but those that have now emerged are so far away that we cannot understand people in the same way. Looking at just the eyes is not the same thing.
Touching is gone. Even if it was just to touch the shoulder as a sign of comfort.
Afonso Braz: It really does make a difference. Of course, if it is necessary to examine a patient, this procedure continues to be maintained, but everything has changed, the bond of proximity that was what gave patients confidence is lost. Because there was a feeling that patients had their “closest” family doctor.
What is it like to deal with public as wide as a baby that was just born and a person who is old and barely expresses himself?
Afonso Braz: This is the most comprehensive area of Medicine, even more than Internal Medicine, which does not deal with babies, but we lack the complementary exams that are not there with us, to know what the person has. Of course we prescribe tests and then we check them, but it is not immediate. But this is the most heterogeneous area, where we will hear “I feel bad” and this can even mean something serious, or generally nothing of concern. What I noticed in in the emergency room in Santa Maria is that many times what the person complained about was a reflection of something else that was not what was said.
Do you miss these complementary tests to better support your diagnosis?
Afonso Braz: Yes, sometimes. That is why in acute situations one has to go to the emergency room. There are countries that offer more complementary diagnostic tests at the Centres and this allows not sending so many people to the emergency room, thus unclogging the hospitals. On the other hand, if we have increased diagnostic capacities, this will clog up the Health Centres. And we already have many tasks to perform, which include periodic monitoring, medication, and following up the entire process of the established programme, which is no small matter. This means that in this specific phase, work did not decrease but has increased, especially because today we have Covid monitoring. We call these people and assess how they feel and whether they can be discharged or not.
Was it necessary to have any special training to monitor these Covid patients?
Afonso Braz: No, but I read articles in order to be up to date. Still, there are services that encourage this learning. And it is sometimes important to accept that we do not know something, because time itself has not yet taught everything. Things take time and we can't speed it up just because we want all the answers, and the same applies to all areas.
Are you afraid of becoming infected?
Afonso Braz: Not personally. I'm more afraid of getting infected and that people because of me people become infected, that would be terrible for me. To imagine that I could cause any harm to my brothers, parents, or grandparents, that would be terrible, not least because we know that it has sequels. As for me, it will not deter me from going to work, because in the end we are health professionals and if we do not react now, then when will it be?
Has this winter been milder regarding request for help for typical winter flu?
Afonso Braz: Not really. We receive a lot of prescription requests, but what I notice the most is that people take longer to come to health centres and even to the hospital. They come to us in an already more serious condition. The pandemic is causing this follow-up problem, not because the professionals do not follow them, but because the people themselves “disappear”. And we will still need to assess the level of decompensation.
What do you think you will do when you finish your 4-year specialty?
Afonso Braz: I have no idea... (he is thinking) I'm still thinking about what I really want. But in the meantime, I am doing a postgraduate course in Sports Medicine. I have always loved sports and it is an area I believe I can work on later. What I know today is that I will finish my specialty.
Are you ready to work until you're 90?
Afonso Braz: It's true, I did say that. (laughs) I think I'll even be able to run then! And I'm going to see lots of movies and series and take a walk by the sea.
Perhaps in the near future he will feel the impulse to leave for Switzerland or Germany, but without a total farewell to Portugal, the country he says he deeply loves due to the way people express their affections and how it is bypassed by the sea.
From the long life he will have beyond his 90 years, he knows that he will always return, since Portugal holds his heart and his true identity.
Gentle and assertive, he denies being praised as brave for having gone to a different culture without knowing how to express himself well, and live in an apartment with others from so many nationalities. “Brave are those who face this pandemic and go to intensive care to work. Or those who get up every day and have to go out to work because they have a family to support”, he said.