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It was one of the last speeches of Applicant's Day, António Vaz Carneiro is the Professor that several students say never fails to meet expectations when they meet him again in class, some time later. The Director of the Institute of Preventative Medicine and Public Health and the Centre for Evidence-Based Medicine Studies is a customary presence on the day that the Faculty of Medicine opens its doors to the curious students who ponder which institute to choose when they enter Medicine.

An easy communicator, he knows that if he tells a story while walking through the auditorium, he'll be able to keep his audience interested.

A specialist in Internal Medicine, António Vaz Carneiro had been in the emergency room at Santa Maria for quite a few hours when he came across the case of a young man who complained about chest pains. Apparently, it could have something to do with the heart, but the exams didn't really prove anything. Anyone with common sense would probably send the boy home, but António Vaz Carneiro decided to hold him for a few hours. "I told him to wait for me in the waiting room. And he did. Five hours later he was still sitting there". There was something in that case that told him he could not send the boy home. He was hospitalised and, on that day, "died twice and was saved twice".

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The Professor is a storyteller. Were you telling a story to capture a potentially distracted audience?

This day is always interesting, as what we try to do is to capture the best possible students for our school. One might question what a high-school grade says when it comes to the skills for being a doctor, this can be questioned. But, socially speaking, we don't have a fairer process, in terms of hierarchy, than a mark. However, from my perspective there are other, much better and internationally well-tested processes that capture the personality of the student. But these processes, for Portugal, are not acceptable because there is a distrust, which is partly justified, and that concerns the fairness of the processes. As such, not being able to capture the subjective, what remains is the objective and that is 18.3 (as grade for admission to the Faculty). Based only on this single metric, we intend to bring the best students to us. You know what's funny? Only two or three universities organize these applicant's days?

Now here is another very important aspect, which is that often the choice made by the students has nothing to do with the quality of the School. It will have more to do with economic criteria and the weight that these financial decisions have for families. Nowadays, it's a drama to support a child in Lisbon. It's unbelievable. We are a poor country and a child costs an average of €1,500 per month. It is not simple. And it has a much deeper influence than what I may suggest. I wish there was an infrastructure to accommodate 35,000 of the 40,000 students in dedicated residences, with proper conditions and at an affordable cost. Yes, the competition would be different.

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Despite social constraints, what are our strengths as a Faculty?

We don't have statistical data that details that we are much better than Braga, Porto or Coimbra. But our added value is the professional opportunity we provide. Because we have the CAML (Academic Medical Centre of Lisbon) and for someone who wants to have a career, the possibilities are not the same if you are in Beira Interior, or here in Lisbon. And even in Lisbon the possibilities aren't the same, it's not the same thing to be here, or at Nova University. We have great research centres here. The people that study here, and that should study here, envision their careers one or two steps above the idea of working as general practitioners at a hospital, for example. Here, we have a really big network of national and international contacts and that is very appealing. And I know that when they get here, they think that there is still a lot to think about, but what I believe is that they should think about it from the first year, because it is a great advantage that we have.

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We also have some weaknesses. Students complain about the student-monitor ratio. That is, there are many students for a single monitor.

We have too many students. The funding is granted based on the number of students, but I think that, sooner or later, it will have to be reduced. Of course it would make a difference if instead of having 390 students we had 90.

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But with the same funding as if they were 400 students...

Yes, that would be totally different. In addition, medical education, from a certain point, has to be tutorial, that is, there are no classes in amphitheatres. From the fifth year onwards, and in the sixth year, there has to be proximity between the tutor and the student, because it is the practical part of the course. So, yes, we have severe restrictions. Another restriction is the lack of capacity to hire people. As such, we have to manage everything with what we have.

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On a day like that, when you receive dozens of young people who are still trying to figure out what they want to be and where they want to go, is it possible to identify a special look right away?

They all seem reasonably interested. My position there is that of a salesman. I stand before them to sell them an idea. And the idea is that this is the best School. I really believe this is the best School, but I have no proof. But knowing Portuguese education system as well as I do, I do not believe there is a better School.

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But if I understood you correctly, you also sent another message. You can be an excellent student and then a doctor who studied all the techniques. But there is a technique that has to be intrinsic and that is feeling. Is this feeling learned?

Yes. This feeling is taught and learned. I can't change people's personality, I can't predict how they will react, but I can teach them behaviours. I can't teach compassion, or sensitivity, or respect for others. But I can explain the importance of these characteristics. Then I hope everything goes well. I can teach people how to think and pass on communication techniques. For example, how do I give bad news, or how do I explain a complex problem, how do I explain the scale of a "disaster" like cancer? These techniques are trained. Then I can only hope that people know how to combine their individual culture with the collective culture of their group and that is the Institution. In most cases we manage to pass on these messages, in others we simply don't. But these values ​​come from home, from education. Medicine is a profession of princes and if people do not bring with them a home education... We deal with people's lives and we cannot go down from a level of royalty downwards. The demands to which we are subject every day require a very independent mental structure and the ethical and deontological foundations must be unshakeable. We cannot have shortcuts or tricks. There is a set of principles, absolutely defined, that must ethically and deontologically guide our profession. These principles are almost second nature to us. But sometimes they have to be taught.

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He recounted the case of the boy who is kept in the emergency room and then hospitalised because something told him that he should stay. That intuition we were just talking about. In the end, what made you hold that apparently healthy young man? Was it evidence, or experience that was speaking to you?

No, there was no evidence. Because the evidence was telling me to send him away. The absence of any alteration in all the exams I did to him meant that he should leave. It is at this point that you enter the sphere of expertise and instinct; these, combined with experience, give us information about reality that science cannot give. Science gives us results for large groups of patients, analysed under very controlled circumstances, with very specific indicators, but it does not tell us how each patient will react. On average something happens, but it is on average. When we go into practice, in fact, average helps and behaves like a "standard". But the question that arises here is related to cognitive psychology and that tells us what some patients have that others do not. And that is very difficult to determine. It was a set of signs, contexts, characteristics and information that I found in that patient, and that I can't verbalise, which led me to say that there was something there that made me forget the exams and do the opposite of what they were telling me to do. This is only taught through role models, through many years of experience and contact with many patients. But there is another side to this and that is, how many sick did I send home, because everything seemed to be well, and failed to have the right feeling? There were, surely, sick people who I failed, where I did not have this instinct. But what I asked myself, what changes is this expertise, something that is acquired after many years of work. The English say that we have expertise when we reach about ten thousand hours of work, that is, when we are about forty years old, the same as saying that that age is when you reach your peak capacity. But it always adds up, because at the age of sixty we're still better. And as long as your head is working well, at seventy you know even more, and are better. Being exposed to thousands of patients is crucial. It is this experience that makes us trace the risk and emergency groups of patients and set priorities. These priorities, however, vary from doctor to doctor.

But then I can also tell you that one day a patient entered my office and I had barely looked at him when I thought "he has a cancer". The man had not even said anything, he only had a few vague complaints that gave no specific diagnosis. I did a series of screening tests and nothing came up. Then I reviewed and performed a second set of more sophisticated analyses and detected a tumour in the kidney. Maybe it was just the colour of his skin that immediately aroused my attention. I did not give up on him. He underwent surgery, and twenty years later we still have dinner every year - me, him and the surgeons. At the age of thirty and based merely on scientific experience, I would not have been able to help him...

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Joana Sousa

Editorial Team