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The view from the historic 6th floor Neurology office at the Egas Moniz Centre of Studies, is not perfect simply because it shows him the stadium of his football club's rival, Sporting. I comment that he plays the role of a king, due to the sum of his career and the names that have been in that office, Professors Almeida Lima, Miller Guerra and, more recently, Professor João Lobo Antunes, but he refutes the idea of monarchy with his republicanism. Indeed, he has made it clear several times that he likes Portugal, the country that made him live through political turmoil and consolidated his patriotic thinking and direction.

Dressed in a white shirt, irreproachably ironed, with blue, double-cuffed cufflinks, he has a cordial posture and maintains an appropriate distance, perhaps a reflection of some shyness together with a demanding attitude. But the striking look challenges whoever approaches him to try to reach a little further into what is just a first reading of his personality.

José Manuel Ferro is Full Professor and Director of the University Neurology Clinic and President of the School Board of the Faculty of Medicine of the University of Lisbon and the supreme body that elects the Director of the Faculty.

Tenacious, persevering, he is very self-critical, and thinks that sometimes he is too hard on himself, as well as on others. "When I was younger, I was terribly scathing". When I ask him where this extreme security comes from, he says that he is not too secure, but demanding and rigorous. The opinions of others have never fazed him, but he still prefers people to like him.

Ambitious since his student days, he looks at today's society as if it is concealed by a spirit of harmony that deprives it of some objective competitiveness. He likes difficult things, and the proof of this is that several of his colleagues warned him "not to dedicate himself to a speciality that had no treatments" and he proved that, nowadays, this is no longer the case, Neurology has and will have more and more treatments. He particularly likes the idea of apparent impossibility in order to prove to others that if "it hasn't been done yet, it's because it's surely going to happen".

This intellectual and professional resilience had already accompanied him in sports, since the time he played rugby in Faculty. Years later he began long distance cycling, travelling across the country for hours, but a fall led him to change his physical rhythm, because his mental rhythm can't be stopped. He started walking, but because he must always have a purpose in everything he gets involved, he set the goal to walk along the entire Portuguese coastline. And he did. It took him 4 years and he proved, once again, that the only things that are difficult are the ones you don't try to do.

He wanted to be a chemical engineer but, after the summer holidays in which he read a striking book about psychoanalysis and got to know Freud's theories and his interpretation of dreams, he finally decided that instead of applying for the Technical Institute, he was going to study Medicine, specifically Psychiatry.

He entered the Faculty of Medicine of Lisbon in 1969. At a time of some "academic and political turbulence, when there was some more free time", he began to work on research in the field of Anatomy. Since he had a very good grade, he then became Monitor, assisting Professor Mario Andrea in his Ph.D. thesis on laryngeal tumours. He would not have guessed that years after "having enough of dissecting carotids" he would focus on the carotid again, this time associated with strokes. But we will get back to that later, because it happened at a later stage.

In 1972, there was a strong group in the field of Anatomy, which would call the shots in the history of Medicine; one of them was António Rendas, who was the Dean of the Nova University. It was António Rendas who started raising doubts about the path followed by Psychiatry, suggesting that he follow Neurology and join the laboratory "of the new researcher that everyone was talking about". This new researcher was called António Damásio, and he was starting, on the 8th floor of the Santa Maria Hospital, a Language laboratory to study language disorders caused by neurological diseases. In November of that remarkable year, José Ferro decided to knock on the door of Damásio's Laboratory and report for work. "Look, I like the nervous system and neurological diseases and I want to come and work with you".

And he did.

It was the 25th of April that led to their separation, because António Damásio decided to leave the country and move to England. Looking back at that time, he not only came to know and work with leading figures like Alexandre Castro Caldas (Neurologist), or Nuno Lobo Antunes (Neuropediatrician), but he also contributed to the work developed by António Damásio and Castro Caldas in their theses. It was on the same field that he wrote his own thesis, about the correlations between Computerised Tomography and Behavioural Neurology.

Always worried with concerns greater than his own circumstances, he became involved in politics. He was an academic leader, a student representative at the Board of Directors, in the last years of his medical degree, and was also involved in the Administration of the Student Association. At that time, he thought that the equitable power between students and the top management of the Faculty was a logical right; today, after years consolidating the solidity of the knowledge and wisdom of life, he bears in mind that everything has its time and that power is something more strategic and elaborated, which must be conquered in a more cross-cutting and difficult way.

He did his internship at Santa Maria and then went to Alentejo, where he was responsible for school health in Arraiolos and provided medical care in the suburbs. Here he continued to develop some research on minor changes to the neurological exam in school-age children and analysed their academic performance. This was a controversial study, since it proved that the academic performance the children who repeated academic years was associated with soft neurological problems that put them at an academic disadvantage.

He leaves Alentejo and returns to the Neurology internship at Santa Maria where he begins to work on his Ph.D. on aphasias and other neurocognitive alterations, due to localised brain injuries caused by strokes. He chose this model and what was then a new method for locating injuries - computerised Tomography.

 

In the 80s, he was awarded a Fellowship at the University of Western Ontario in Canada, to work in a renowned Centre for Vascular Cerebral Diseases. At the time, when he already had two young daughters, he was forced to stay away from them for a year. "It was a bit hard because at the time there was no Skype, no mail, no whatsapp”. He fears being considered too traditionalist, but it was the family support he received from his wife, also a physician, that allowed him to fly higher, as she endured being by herself for a while.

Today, at 40 and 37 years old, one of his daughters is pursuing her studies in the field of Psychology and also works at Santa Maria, and the other, despite being a nurse, chose to take on the full-time role of mother of five, but does not neglect her new training in Dentistry.

He could have stayed in Canada, as his family would have took on the challenge with him, but once again the pleasure of living here and the challenge of improving Portugal called to him and he returned. When he returned, he gave full meaning to the term "doctoral intern", as he finished his doctoral thesis and internship virtually at the same time.

He stayed at the Faculty of Medicine where he was hired as an Assistant and worked in the field of Behavioural Neurology for some time. Because time has always made difficult things less demanding, he continued to enrich his journey by changing the subject of his research. This time he was interested in the Cerebrovascular Disease, so, instead of focusing on the neuropsychological consequences of the disease, he started to dedicate himself to the Cerebrovascular Disease itself. "First of all, to be good in the other field I needed to study a lot of Psychology and Linguistics, which were actually very far from my field of expertise, as I am a physician. And the other reason is because, at that point, what had been done in cerebrovascular diseases was virtually nothing".

Until that moment, and except for Professors Nogueira da Costa, Pereira Miguel and Professor Pádua, no one was treating or following-up stroke patients, as "the focus was only on heart disease at the time". The first team was formed in 1985, by physician José Ferro. The first step was to offer external appointments and so the team grew to be eight strong. In 2001, the Stroke Unit was formed.

Very well-known in the cerebrovascular milieu at the European level and globally, it was mainly focused on the diseases that affect the veins in the brain, leading it to become a world leader in that field. Another focus of his research has been the neuropsychiatric consequences of strokes. In fact, he returned to the beginning of it all, when he wanted to study Psychiatry, Stroke Neuropsychiatry and the psychiatric consequences arising from injuries caused by strokes.

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Professor, was it easy to forge this path? The first Stroke Unit opened in 2001, right? It wasn't that long ago...

José Ferro: It's never easy because all changes are difficult. In Portugal you need lots of tenacity, because you have to know exactly what you want and you have to be stubborn. It's all very slow, and there's a lot of passive resistance. Compared with other countries, like Canada, where I worked, it's clear that there are less resources here. Look, one thing that is happening now is that we are finally going to have works here in the EEG laboratory, to turn the laboratory into a neurophysiological monitoring unit that will allow us, not only to do research, but above all to very carefully select patients for surgery, to treat them for epilepsy once and for all. We developed our first project in 2004, and the decision to finally carry out the works and to start them was only made last year, more than ten years later. As you can see, one must never give up. But also, it is very important to have fun with what you do. Another thing that makes me really happy are the Ph.Ds I've been supervising. I've supervised eleven so far, but I still have three to go.

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Do you learn a lot when you supervise someone?

José Ferro: The best thing you can do is work with a Ph.D. student; when you have a good project, you must have an excellent Ph.D. student. These people, in the early stages of their careers, have a different energy.

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Do you think they will follow your ideals and the path you've forged?

José Ferro: Exceptional people, regardless of the field they work in, are rare, a Ronaldo, or great musicians, or great painters, only appear from time to time. Physicians and researchers, with great quality and with leadership skills and vision, only appear from time to time. Every seven or eight years. Well, every 5 years an intern shows up and we say "well, this one may just get there..." But they appear, of course. It's important to say that when people cross skills, they get stronger than the others.

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You were a pioneer in Portugal in the field of post-stroke psychiatric disorders; is this also a pioneering field, internationally speaking?

José Ferro: You could say that, because there have not been many people to take a continuous interest so far. We rely on the collaboration and vast knowledge of Professor Luísa Figueira. We have had various psychologists who have worked with us precisely in these areas; Lara Caeiro, who is still working in our team and did her Ph.D. on Post-Stroke Apathy, and Catarina Santos, who explored the other extreme, and is about to complete her Ph.D. on Post-Stroke Anger.

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It's interesting to see how Medicine has evolved and opened new doors, always keeping up with the times...

José Ferro: There is one thing that I always say to the interns: "when you are practising medicine, you have various dimensions - science, biology, the clinic, the profession itself, the social dimension, the human dimension and also the research dimension. In other words, you have to stay permanently curious, if you want to do clinical research. Furthermore, you have to question yourself. If you look back at your day of clinical practice and ask yourself "what I did, this decision I made, what is the proof that supports it? The choices that I make throughout the day, are they all scientifically correct? Well, on that day you leave with a work portfolio for the next ten years, because there are thousands of things left to know and so many other clinical research questions left to ask and answer.

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Do good physicians have to question themselves a lot?

José Ferro: They do, but they also need to be pragmatic. Because they have to make decisions. But research is important, because it allows physicians to take a critical view of what they do and what they learn. Everything in life changes nowadays, but Medicine changes dramatically.

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Tell me about the link between the iMM and the Laboratory.

José Ferro: It's very straightforward, because what I do is "pure and simple" clinical research. Currently, we also have some projects with biomarkers. I don't do lab research nor research on animal models. We have clinical trials and observational studies, and now I also included serum biomarkers and genetic biomarkers, hoping they may advance knowledge in relation to the others we already know. We have a cooperation with the Higher Technical Institute (IST) in which they give us precious assistance in one of the most difficult things in Medicine, which is making accurate individual prognoses. The way we are reaching individual prognoses, nowadays, is very limited, there are still major errors in our predictions.

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That makes me think about Alzheimer's disease, and about how difficult it is to draw a real picture, with a timeframe, of what is going to happen to the patient...

José Ferro: There are many families that ask me, when is my mother, who has Alzheimer's, going to have to be institutionalised? Many times, my answer is that it's not worth worrying about decisions that will need to be made so far in the future, because often, in the short term, completely improbable advances occur. But the truth is that there isn't an algorithm that allows you to answer that accurately, and the ones that exist have an unacceptable margin of error. But we will get there, because by using Big Data and Machine Learning computer techniques, it will be possible to improve our prognostic models.

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But this poses another question, will the "human doctor" be in the hands of the "artificial intelligence doctor"?

José Ferro: No, that is the same as saying that computers, or the internet are bad. Progress is always good, it can be badly used, but historically speaking it is good. Some years ago, when I had a doubt, I would look at a book, or ask someone older than me. Nowadays, when I say that a case should not be treated in that particular way, interns immediately validate whether I'm right or wrong on PubMed.

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And what has more weight, the wisdom brought by time, or the information compiled online??

José Ferro: Well, I would say wisdom. But I got used to confirming things myself. They are paradigm shifts. Every step of clinical reasoning is associated with a medical decision and in every one of these steps there is always a certain level of uncertainty, which doesn't prevent us from taking action. I'll give you an example, a person has a complaint, the first thing that I have to decide is the relevance of the complaint and then progress in my decisions, reducing my uncertainties. A machine that cross references data, all together, can be useful for rare diseases. But there is one issue, which is clinical maturity or, in other words, the more clinical cases you see, the more you get to know the problem. Then it has to do with your experience in contextualising information, if you are inexperienced you don't know how to contextualise it.

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When people ask you for an appointment, is there always an underlying pressure or demand to solve your patients' illnesses?

José Ferro: I don't feel that pressure. But there are days when you deal with cases that hit you harder, especially the ones that go badly. There are days where I say "why don't I work in a restaurant or in a bar instead?" Sometimes it's heavy, because I look at the profiles of my patients and they don't tend to improve, they get worse, it's typical of many illnesses. There are moments where you look at a patient and you don't fully understand what is wrong, and what the reason for their clinical instability is, and then, those cases keep buzzing around in your head. But this job is very emotionally rewarding, it has many positive aspects about it, otherwise you could not take it. You know that every week I need to clear doubts. One of the things that I now do at this Hospital is to visit patients in other services. There are many patients with neurological problems who are in other areas and now, with the ageing population, there are many patients with Dementia, Parkinson's, etc., admitted to other services. Many times, before examining these patients or while going to the service where they are hospitalised, after re-reading the electronic request for observation, and because sometimes they are very complex or rare situations, I will do a survey of the latest publications related to that problem.

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Do we have more and more neurological diseases?

José Ferro: We do, because there are more people living past the age of 80. Today, Alzheimer's disease is an epidemic, nearly all of us are going to have that or another neurodegenerative disease, if we don't die from another disease before that. If we resist almost everything in the range of other diseases, we will end up having a neurodegenerative disease. In the 80s and 90s there were very few patients with Alzheimer's, today the main reason for seeing a neurologist is related to this disease. During a period of appointments, four out of fifteen patients suffer from Alzheimer's disease, or fear they have it.

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Do you have goals that you still haven't met and don't want to give up on?

José Ferro: Yes, I do. Scientifically speaking, I have to complete three projects on Cerebral Venous Thrombosis. I would like that two of the collaborators who work with me, would already have their own teams set up, in cruising speed, when the time comes for me to leave. But I believe that I've exceeded my own expectations. At the moment I still have too much work in my hands.

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Joana Sousa

Editorial Team