News Report / Profile
João Eurico Cabral da Fonseca
João Eurico Cabral da Fonseca is a Full Professor, Director of the University Clinic of Rheumatology and of the Institute of Clinical Semiotics of the Faculty of Medicine of the University of Lisbon. He is the Director of the Department of Rheumatology of the Lisboa Norte University Hospital Centre, Santa Maria Hospital. He also coordinates the Rheumatology Research Unit of the Molecular Institute of Lisbon (IMM - João Lobo Antunes).
As a student in the Faculty where he now works, he actively participated in several initiatives aimed at improving and diversifying teaching, namely as a member of the Student Association. Now in different ways and with a broader perspective on the institution, he looks back on those days and fully understands the students of today. And, thinking about the old days, he reflects the reason for his professional choices.
It was when he met Professor David Ferreira that he became interested in Rheumatology. David Ferreira promoted "mini congresses" in which the students gave oral presentations and made posters, based on articles he handed out to his classes. Following a participation in one of these sessions, the Professor challenged him to spend a month at the Gulbenkian Institute of Science, the only biomedical research institute that existed in Lisbon at the time. Not only did he take the opportunity, but he also returned in the following summers. It was purely by chance that he found "a number of markers of communication between the cell nucleus of the cytoplasm, which were a series of proteins against which there were circulating antibodies in certain rheumatic diseases". His interest grew when he moved on to clinical practice and joined a project led by a rheumatologist, Dr. José Alberto Pereira da Silva, coordinated by Professor Carmo Fonseca, in which he studied an animal model of arthritis. He spent many hours studying that model and getting closer and closer to matters related to Rheumatology. At the same time, at the Faculty, he was studying, with the same intensity, and building up his knowledge about diseases related to arthritis, such as lupus, vasculitis and rheumatoid arthritis.
When the time came for him to take his specialty examination, he had no doubts that Rheumatology was his "bite-size evolution".
In the early stages of his career as a researcher, when there was no physical vivarium, animals for studies were kept at the Gulbenkian Institute of Science. When he returned to the Hospital, he had to sneak past security to go into the laboratory with the animals. But his "portable vivarium" didn't always go well. One time he was barred from entering the hospital by the security guard, who argued that animals were not allowed inside, so he went back and realized that he had to find another way to get in. He jumped over the fence and, balancing between boxes, he arrived at the laboratory.
While during the first six months of internship João Eurico was able to live between the hospital and the laboratory, after completing his military service he realized that the time had come to dedicate himself fully to medical practice. And that's what he did, for 3 intense years. Only at the end of the internship was he able to resume his project of having a clinic that could have its own laboratory. "Jo Edwards was my tutor in London and lived exactly as I wanted to live at the time. He saw patients on the first floor and had a laboratory upstairs. I returned to Portugal with that ideal".
Back home, and once the iMM opened its doors, he combined clinical practice with research. "I knew it wasn't going to be easy, but it turned out to be even harder. My efforts between the hospital (Egas Moniz at the time) and research eventually led me to become the partner of those who were working full time as scientists, with their brains entirely focused on science". The encouragement he received from professors Viana Queiroz, Lobo Antunes and Carmo Fonseca gave him the resilience to never give up this very demanding career, developing research works related to patients and focused on the interaction between laboratory and clinical researchers, using clinical data, human biological samples and animal models of human disease.
The creation of the Biobank and the Clinical Research Centre, in which he was involved, were two of the ways he found to cross synergies between the two professional groups - scientists and physicians - turning them into a cohesive and complementary team.
A strong supporter of the quality and potential of the Campus, he greatly respects the historical past of an Institution he sees as his first professional choice. He says that thanks to the collaboration of many people who have worked here, some of them anonymously, our environment has excellent conditions, but there is always room for improvement. The hospital structure, together with the Research Institute (iMM) and a great medical school provides the arguments and strength for team work. Nevertheless, he regrets the fact that the Hospital is under such great pressure, because it receives both patients with mere colds and those with clinical conditions that no one else is able to treat.
Did you annoy some people when you studied at the Faculty?
João Eurico: (Laughs) Unintentionally, yes. There are two important moments I'll never forget. One, was that, by coincidence, when I was a member of the Student Association, it was its 75th anniversary and we decided to celebrate it. We reconstructed the history of those 75 years, but it was not easy, because there were not many public records of the past. So we interviewed older people and we went back in time until we got to Professor Baraona Fernandes, who had been a member of the Association at the beginning of the 20th century. He gave me a series of notebooks on health prevention made by students. There were already lots of initiatives at the time. But the other defining moment I remember was the historical opportunity to become a member of the Pedagogical Council (CP), as student representative, at a time when Professor Lobo Antunes was President. He was very committed to implementing some disruptive initiatives. One of them was to try to conduct the first student survey on teaching at the Faculty, something that had never been done. At the time he needed practical support, someone to ask the questions, to write the text (you should remember that there were no word processors like nowadays) and I had that opportunity. I was able to think about the questions and discuss them with the most experienced people in the CP, then I put them together and made the final layout. Then I was involved in the implementation of the survey, addressed to all the students, at a time when there was no internet. We had to be there in person, talk to the students and get them to answer, because the validity of the process depended on the number of participants.
And were there many participants?
João Eurico: Yes, and the results were not bad; but they were very critical with regard to some issues and the community was not prepared for that criticism, much less for the survey to be publicized. That happened in '92 and, at the time, the leadership of the CP talked to some people and, to prevent the results from being concealed, the date was processed with a statistical analysis. That work, led by Professor Lobo Antunes and Professor Leonor Parreira, was turned into a scientific publication. This process made such a strong impression on me that later on, as a Professor, I continued to use it in my classes, at a time when there was no survey at the Faculty.
And now, as a Professor, how do you deal with criticism?
João Eurico: Feedback from students to professors is a curious thing because, as human beings, we're not very fond of criticism, so when we get criticized, our first reaction is negative. This culture of humility that we have to practice is related to professors and has a connection to the scientific phase of our career. Let me explain, the criticism of the papers we submit to scientific journals is horrible! We submit our work and then we receive a letter listing everything that is wrong. I have about 250 articles published in PubMed and for sure most of them were submitted to journals several times; perhaps times three, because it is common to submit papers to three magazines on average, so I probably received about a thousand letters criticizing articles. Of course that, when faced with that criticism, the first reaction is a sense of injustice, so we shouldn't reply immediately. Then, after a while, we reread everything more calmly and realize that, in fact, there are a number of things that make sense. And with the criticism from students it's more or less the same; at first we listen to them and we think it's a great injustice, but then, with a little more distance, we realize that one idea or another make more sense. We should talk to some of the students to get direct feedback, because it makes it a lot easier to understand them later on. In human contact, even the most critical people become calmer over time, and what was written and seemed more aggressive, gradually becomes more understandable and less aggressive.
So, do you listen to those with more reactive attitudes?
João Eurico: I prefer to liaise with the official representatives, who give me average opinions, as that allows me to understand the seriousness of the matter that is being criticized. In these conversations there are very pertinent remarks on things that should change immediately. Then there are other remarks that are not so clear and we have to understand them together with the students. Now, the fact is that these surveys are a good autoscopy for professors, because they allow them to realize what needs to be changed. But we also realize that certain aspects shouldn't change, despite the fact they aren't successful. This is difficult to manage, but there are also some processes that are difficult to change, particularly when we're talking about very long courses and the need to interact with the players in the education process. It's a cascade process. Those who coordinate the subject have to pass that feedback on to those who teach the subject. And that's difficult.
That's exactly what I was going to ask you. Here we're on a different level of communication, communication between professors, but still it isn't easy.
João Eurico: Here we have to talk to other colleagues about the criticism and about the problems we're having; they are not aware of them and they react adversely to the criticism from the students and the chair. Chairs have their resistances, other professors have resistances, and one of the most resistant groups are physicians, they are conservative about innovation. Do you know why? Because they are afraid that this innovation is not completely tested and, therefore, not completely safe. The same applies to us in teaching, when we are innovating, people question whether the change is truly useful and whether it will be worth implementing.
Did the fact that you studied at this faculty and were used to expressing your opinion at the time help you to have a better idea about how to position yourself as a Professor?
João Eurico: It helped me a lot. I have no doubt that I'm particularly sensitive to feedback, for better or for worse. When I get feedback I'm very receptive to it, I'm not at all insensitive. I'm very receptive to it and I have to process it appropriately. I don't have a shell to block out feedback.
Those who work with you describe you precisely as someone who is very thoughtful and who doesn't make a single decision without thoroughly evaluating all the issues involved. Doesn't that wear you out?
João Eurico: I'm always doing it. I listen, and listen, and listen... and then I have to make a decision. Then, when I make it, I totally stand by it and it becomes increasingly individual and less collective. But I don't know if it wears me out, it's my way of living life.
Then there are other curious pieces of information, that you are a workaholic, that you never fail to reply to a single e-mail, even on Christmas day or on weekends. And that you come to work at 7 a.m....
João Eurico: Workaholic is a complex word. (Laughs) I work long hours and I have no doubts that I work more hours than average. Since I was a child I have a biological characteristic, I sleep relatively few hours. If I sleep six hours I'm fine, my bio rhythm is in the morning. That's why my day starts early; at 7:30 a.m. I'm usually on campus. But before I come I do some more intellectual work; it's when I write and review articles because it is the only time of day when I have some peace and quiet.
It's easy to understand why, you have Rheumatology, you have teaching, you have your research laboratory at the iMM. Am I missing something?
João Eurico: No... It's demanding, of course. But many of those things are done together, some physicians give classes and do research at the same time, partially overlapping the three activities. It's not just me. Then there are people who do research, who don't work as physicians and do research with me, for some years now; they're very close to the general team and that makes me feel that I work in a very good environment. I think I've been very lucky when it comes to the people I've worked with; they have extraordinary characteristics, a good work capacity, and strong interpersonal skills.
Are you lucky or were you able to encourage them to work as a team?
João Eurico: I believe that, to a great extent, I've been lucky with the people who have come to work with me, and then we've indeed managed to turn the group into a team; each person adapts gradually to the process that makes us all go in the same direction. In other words, if people feel that they're working as a team, then they no longer have the individual will to escape from this team. Even the most individualistic ones refrain their individualism when they see that the team is working.
What inputs do you need to give to keep your team motivated?
João Eurico: It's very important to communicate, and you have to be objective. You need to be aware of the moments when you have to give individual feedback and be constantly available to do that. We must be fair and properly reward, to the extent possible, those who produce more, those who are more skilled. But it's also important to find out if there are people with problems and try to help them. Then we have to try to look at what is happening as a team. I always try to be as present as possible in other people's lives, but I have the notion that sometimes things go wrong for me too. Sometimes I'm unfair and, on several occasions, I had the frustrating feeling of having made a negative comment, at the wrong time; I could have waited longer, I could have put more thought into the matter. But I always try to improve on that and avoid, as much as I can, to be the disruptive member of the team. One shouldn't rattle a team where everything is going well, but if, for any reason, it shakes, then there is the need to act again. One shouldn't act too much, expose too much, appear too much, wear out one's image. This is important to ensure that everyone has their own voice and space, which are crucial for things to work out.
The issue of time management reminds me of one of the remarks I usually hear from students which is the fact that professors don't spend enough time with them. They make a comparison with Nova and point out the professor-student ratio as a major weakness. Are they right? How can you reverse this?
João Eurico: Yes, they're right. And that's a serious problem. When I got into the Faculty we were only 40 students in my year. Now there are 360 and, in some years, nearly 400. The structure is similar to the one that existed when I was a student; of course there were fewer professors in those days, but this makes teaching hard to manage. In my opinion, this is a problem inherent to the characteristics of the Faculty and that is now forcing professors to juggle multiple tasks. The only solution is to divide each year as much as possible. We have to create various groups and use different teaching methods; for example, face-to-face classes with the entire year in the theoretical components and the electronic interface (Moodle); but then the compulsory curricular components, theoretical-practical classes, seminars, practices, have to be taught to groups that are as small as possible. That means having different things in different years; I find it reasonable for a theoretical-practical class to have 20 students and a practical class to have 10/12 students in the pre-clinical years. In a 2-hour class where students are supposed to ask questions, there should be 20 students at most.
On the other hand, in clinical teaching the number has to be different; you can't have more than 4 students around a patient and that means dozens of classes. If you imagine 400 students, in a year, it's almost 100 classes. This fragmentation requires us to have many assistants available, but it also raises complicated logistical problems. We need to make sure that all the people who receive students are in a position to receive them. And we're not entirely sure of that. I'll give you a practical example: I'm responsible for the 3rd-year hospital internship in which we have small groups of students, 2 at most, who, in turn, have several tutors. For 6 years, the students will have dozens and dozens of tutors. I'm not sure that everything is going to go well with all the tutors. I can control the person responsible for these tutors and pass on messages, but I can't do it individually. But this also happens in practical classes where we have 4 students and dozens of assistants and, of course, we're not sure if they're all truly motivated and available. Of course this can cause problems, but I believe they are occasional. Then there is also another scenario which has to do with theoretical-practical classes and seminars, when we have more than 20 people in a room and we need to create interaction. It's very difficult to get people to actually participate, some of them get completely distracted, they're simply not present. Then there are people with more leadership and interaction skills that end up taking over the class. In this situation it's very difficult to get these people to slow down and give negative feedback because they are participating, but at some point it is necessary to stop them because there are others who want to talk.
How can a good student become a good physician in this reality you are describing? What makes them so special compared to others?
João Eurico: They are more demanding people who take every opportunity we give them and make the most of every opportunity. I would say that there is a group of students who are the best here and would always be the best, regardless of where they were.
Can you spot them easily?
João Eurico: Of course! They are extremely competent students who would be competent in any faculty in the world. When they are faced with a new reality, these students try to understand how everything is done, they try to learn everything, they are highly self-critical, dedicated and demanding, with themselves and with others. Consequently, despite this difficult teaching environment, with a heavy workload and some lack of engagement, they always manage to demand. When they are with a professor they immediately make demands and, in doing so, they learn and make others around them learn, putting everything on a different level. In addition to that, they are people with strong interpersonal skills and therefore, when the time comes to interact with patients, they have no problems at all. Then they move forward, and move forward, and when they get to the last year, they are clearly ahead of all the others. But the main goal of the Faculty is not to have these extraordinary students; its goal is to create a minimum threshold of the highest quality that can be achieved and not let anyone below that threshold to move forward to the following year. When you reach that threshold, we consider that to be the minimum. Then, when they actually have to deal with patients they are very well trained because they absorb all the scenarios. Another step is being able to retain the best in our academic centre. But this Hospital is very tough and demanding and that makes many students want to leave and this, of course, affects our ability to recruit the best.
Let's consider a completely fictitious scenario which is based on the budgetary constraints that we know that the health sector is facing. How can you be a good doctor if you don't have the necessary resources and materials to assist an urgent patient?
João Eurico: Here in this Hospital the problem is not failing to treat patients for lack of financial resources. The main problem is the huge number of patients that is putting pressure on the Hospital's structure. The Hospital isn't able to respond in a timely manner, but it always responds with the most appropriate means from the technical point of view. The problem is the disproportionate workload. This Hospital has to teach young doctors, teach medical students, deal with the most complicated cases, while working with a referral system that is free, meaning that we receive all patients, regardless of the severity and complexity of their conditions. All this puts an enormous pressure on the whole structure that makes life very difficult for the institution's human and financial resources. This is a piece of a very important puzzle that the national health system has to solve.
Crossing so many initiatives and managing so many areas. Is there room for you to be just you?
João Eurico: Well... Right... I try to find room in this activity to be just me. For many people within my relationship circle I'm just João, and for this other professional universe to work so well, I do sometimes have to be just João. These people in my personal life actually allow me to be more humane in my activity. If I was only driven by technical reasons, I wouldn't stay motivated. I make an effort not to affect my personal life.
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For the future success of the Hospital and its doctors, João Eurico da Fonseca expects that the minor, first-line cases may start being referred to other nearby hospitals, thus reducing the Santa Maria Hospital's exposures to the ups and downs of the national health system. Still, on a positive note, he finds that the fact that doctors have to deal with all sorts of realities is a fantastic training opportunity, giving them an educational baggage that can't easily be found elsewhere.
He continues to feel the responsibility of supporting the Campus, the Medical Academic Centre of Lisbon, of which he is a member, strengthening the key role played by each element: Faculty, IMM and Hospital. According to him, it's by coming into contact with these three realities that doctors become more professional and scientists come closer to the clinical reality.
Who wins? The students and the Faculty.
And all the patients who will always continue to exist.
Joana Sousa
Editorial Team