We met in one of those happy encounters that will remain a strong human contact for life.
Presented by Professor Joaquim Ferreira, I knew very little at the time, almost just her name and that she was working on her Ph.D., reason that linked her to the Professor. The second reason that connected us all was the start of the FMUL talks, a project by Professor Joaquim Ferreira and coordinated by Ana Tornada.
With blue eyes and light hair, the peaceful smile shows contagious confidence. Hers would be one of those faces that we would want to see if we were on a flight with turbulence. Her look would reassure us that the flight would be safe. In fact, she also panics about flying, but she doesn't let fear hold her back and when she had to fly to the US alone to attend a congress, she went anyway.
Ana Tornada is a specialist in Internal Medicine and graduated from the Faculty of Medicine of the University of Lisbon.
After five years doing the specialty in Medicine 1 and a year doing a full-time master degree in London, in the area of the prevention of cardiovascular diseases, she went to Cascais Hospital already as a specialist. As a recent specialist, in Cascais Ana Tornada started by leading emergency and infirmary teams, feeling “often the isolation and increased responsibility of working without the support of other specialties”. She stayed there in her first four years, a time that she reinforces as “a great school” and essential to learn how to be “a full-fledged internist”.
This was followed by her Ph.D. and the return to what she calls her “home”, the Lisbon Academic Medical Centre (CAML), with a special connection to Santa Maria Hospital and to the Faculty. All factors came together to indicate she should stay and build a solid path, because if, on the one hand, she was doing research on decubitus hypertension, which she herself will explain to us, on the other hand, she came in contact with a new pleasure, to teach. She immediately corrects me, saying that she does not teach, she "guides students and interns". Teaching classes to year 4 students of the IMDM, she also supervises internships for year 6 students. Occasionally, she receives students from other national and international faculties in mobility programmes.
We have been talking and dealing with common topics for many months. It was in the intervals that I observed and admired her discreet and silent path. I sometimes asked her, "Can I talk about you now?" and the answer was always "not yet, but when the time is right, I will let you know ". And so it was.
It would be very limiting to talk only about the subject of her doctorate, since she has done so many other things. It is worth talking about her rhythm in the emergency room at the end of the morning shift, when she met with me and her eyes showed tiredness; or her endless work with the students who accompany her and drink from her knowledge; or the strategies she found to help reach a patient who wasn’t hers, in the middle of the Covid peak, just to bring comfort. This is the Ana Tornada that we want to talk about today, because it is the whole of her that further enhances her. The same person with whom we did not validate this introduction, because otherwise she would not allow it due to excessive visibility. But we took a chance, nonetheless, because we admire her so much.
Can we talk about your Ph.D. thesis and connection to Professor Joaquim Ferreira?
Ana Tornada: My Ph.D. project aims to assess the impact of an entity about which little is known so far - decubitus hypertension. We have all heard of high blood pressure and its health risks if it is not properly diagnosed and controlled. However, some people only have high blood pressure values when they are lying down and this is called decubitus hypertension. Some may even have very low values at the same time when they rise, the so-called orthostatic hypotension. When these two situations coexist it is very challenging to balance medication and maintain a relatively normal life.
What I intend to study is the impact of decubitus hypertension (when lying down) and see if that risk comes close to the so-called essential hypertension, which can cause brain, heart, kidney, retinal and blood vessel damage. If this proves to be the case, the next challenge is to find ways to balance the mechanisms of blood pressure control, either in a standing or lying position.
The population I am going to study, in terms of both frequency and impact of decubitus hypertension, is that of Parkinson's Patients. It is a model of disease in which, with some frequency, there is deregulation of the control mechanisms of the so-called autonomic functions, which are behind the adaptation to the position adopted by the body.
That is why my association with Professor Joaquim Ferreira is very obvious, as he is a professor who has dedicated much of his clinical and academic life to Parkinson's patients. A few years ago, the Professor posed me the challenge of working, from the perspective of Internal Medicine, on an integrated and multidisciplinary project involving Parkinson's patients. It was when my interest in autonomic dysfunction and all the comorbidities that affect this population started. Hence the need to deepen knowledge and conduct research in the area of hypertension and dysautonomia, which has become the challenge of the CAML doctoral project.
Professor Joaquim Ferreira gave me all his support and encouragement to develop this idea and create an innovative project. And he has always been available to offer support and stimulate critical thinking, essential to proceed with a project of this dimension.
How has this dual role of teaching and receiving internships in such a complex area of knowledge as Internal Medicine been?
Ana Tornada: The contact with them and with the academic life makes me miss the Faculty days, everything... from the awakening of my taste for Internal Medicine, the most pluripotential and integrating specialty I have ever known, to the challenges of reconciling studies with the academic spirit, organizing Faculty events, both formative and playful, to develop as an independent young woman living outside my parents' wing. Finally, live a full life.
The choice of specialty became logical from year 4 of the degree, then came the internships and contact with some assistants who inspired me and gave me the strength to continue this path.
It has been a pleasure to transmit some structure in the assessment of patients as early as year 4. At this stage, everything is new, from entering the ward for the first time, talking and touching a sick and often fragile person, organizing the clinical interviews, interpreting and reasoning about what was heard and seen from the patients, about what was read in books and treatises, about what has been taught over the past few years. I like to see the dazzled way in which some students react to this experience and I like to encourage them to integrate all knowledge, all humanity and maintain the humility of continuing to seek knowledge to solve problems.
In year 6, it is a little different, students are more mature. In general, students are well prepared and very interested in assuming the role and figure of the “doctor” before patients and their families. This is a crucial period to absorb all the explicit and non-explicit information about what it means to BE a doctor. Routines are acquired, teams are worked on, the ability to register and communicate what is relevant is trained, what is frequent and what is rare is observed, confidence and autonomy are gained. Regardless of the course they take, I am sure that this is one of the most striking periods of the degree.
There is also being on call in the emergency room. The emergency scenario is always the peak pressure for any doctor. But how is being on call at the ER experienced today?
Ana Tornada: Undoubtedly with some anguish and concern. We have to manage a variable number of patients, a plethora of clinical problems of greater or lesser severity, an organizational structure and a team of people. The Emergency Service has undergone multiple transformations over time. There is a pre- and a post-Covid19 era.
After this last year living in a pandemic, there has been an essential restructuring of emergency care services, allowing hospitals to focus more on critically ill patients and primary health care on the less severe patient, which allows a broader time window for solving their problems. On the hospital side, we are constantly experiencing the need to strengthen teams, adapt procedures to ensure maximum safety, manage the stress and frustration of dealing with a new disease that sometimes behaves differently than expected, and with limited resources, work more hours so that we could support each other and at the same time manage each other's personal and family problems. The updates of internal and external procedures were practically daily, we live in a very intense and focused period.
How do you deal with unpredictability on a daily basis?
Ana Tornada: Effectively, even when we have been doing this for a few years, we are faced with the unexpected, with what is not even shown in the movies. The best way to deal with the unexpected is to think and act with structure. We start by analysing the situation, identifying problems and priorities, allocating tasks and adjusting to needs. When we work as a team, everything becomes more fluid and the discussion of ideas is usually fruitful to solve every unforeseen event that arises.
We went through an atypical moment of pressure and stress. How do the roles of Ana the doctor and Ana when she leaves the hospital balance out?
Ana Tornada: It is a balance that is constantly challenged. In fact, there is an immense workload when we are involved in multiple activities and even more so when one of them requires practically exclusive dedication, as happened with clinical activity at the height of this pandemic. Family and friends are often put on hold, but never forgotten, they understand that this is a way of life and that every Christmas, every Carnival, or every holiday, it is necessary to safeguard everyone's health, and that some of us we will have to be working. It is often the rest that is compromised and this is reflected in the dark circles around our eyes.
Are you ever afraid that you put yourself at risk when you help others?
Ana Tornada: One of the things that training and experience give us is the wisdom to reasonably assess the risks, before throwing ourselves head on first. It is also necessary to be a little lucky, take a big breath of courage and keep thinking about each step taken and how to go back, if necessary. Thus, we almost eliminate fear, at least when it comes to acting. Sometimes we have no more than a few seconds to make a decision, whether to move forward or lose an opportunity forever.
As a doctor, can you always make the decision you think is the right one, or are not all decisions just in the doctor's hands?
Ana Tornada: Not all decisions are in the doctor's hand, that must never be forgotten. When dealing with people, everyone has expectations, ideas, problems and experiences. Then we will also realize that there are several ways to deal with the various problems that arise, certainly with different results, but equally valid in view of the expectations created. The most important thing is to create opportunities to solve problems, encourage, accountability and support regardless of the results.
Accordingly, I really like the Cardiovascular Risk consultation because there I can influence people's health and life so that they never “feel” their disease, that is, never have symptoms or events, never go beyond the risk group in which the disease is already established, compromising their quality of life.
But in this specialty, we also have the possibility to monitor people in the various stages of the disease, even in conjunction with other specialties. Sometimes, patients come to us at a stage when it is no longer possible to strengthen the optimism of the cure or longevity. I would say that this is the situation that leaves us most vulnerable and that demands the most from us as clinicians and human beings.