News Report / Profile
Between yesterday, today and tomorrow: An interview with Professor António Vaz Carneiro
We usually seen him walking at a fast pace along the corridors of the Faculty of Medicine. He's a jack-of-all-trades and those who work with him say his agenda is chaotic. With his very own rhythm, Professor António Vaz Carneiro needs no introduction. The FMUL was the stage of many of his academic and professional achievements.
“Owner" of evidence in Portugal, Professor António Vaz Carneiro devotes much of his time to the promotion of scientific studies aimed at raising the public's awareness of the myths and not so dogmatic truths regarding public health.
He was born in Vila Real, in Trás-os-Montes, on February 28, 1951. As the son of an engineer and a typical 1950's housewife, he grew up in a traditional family. Proud of his roots, he says that the world was completely different at the time: "A 1950's provincial town was an extraordinary thing! It had an absolutely unique lifestyle. ”.
Not meaning to intrude on your family life, is there a more personal reason for you to choose Medicine that you would like to share with us?
I didn't choose Medicine because I had talent or a special calling. I chose it because I wanted a life without bosses. But then, of course, medicine changed a lot and I often had to deal with bosses (Laughs). I wanted to be a "solo craftsman", I didn't like the idea of working in an office from 9 to 5. That wasn't my model of happiness. Although I see myself as a competent physician, I had no special talent at the time, so I think I would also have become a good engineer. Strictly speaking, being good in a profession has little to do with talent and a lot to do with work.
So you're challenging an idea: When there is a current of thought that argues that a good physician, a good future physician, should be both a good student and have a vocation...
Vocation helps. But, nowadays, clinical practice has nothing to do with what it was 40 years ago when I graduated. The kind of vocation I needed 40 years ago is not the same kind of vocation I need today. I take pleasure in taking care of people, but clinical practice is a very difficult option, sometimes very tense, because we have to deal with pain and suffering. From my perspective, above all, the talent to be a good physician has to do with the way you understand patients. Medicine has undergone major changes and, in that context, the vocations that you had at the time are very different from the ones you need nowadays. The medical profession is practised by large systems and no longer by "craftsmen" and there will come a time when individual physicians will disappear. Patients will be assisted by teams: hospital teams, primary care teams, long-term care teams, etc. Teams that replace each other.
And where does that leave the patient-doctor relationship?
It will tend to be replaced by another form of relationship.
So, it's not important?
It is, but it will be lost. Patients have certain expectations regarding doctors and also certain expectations regarding the system that is going to treat them. But, usually, they don't know either the doctor or the system. And they will never be able to fully know them. Despite good intentions, patients don't understand the risks, the probabilities, the physiopathology of their illnesses, in other words, they don't know what is likely to happen and, therefore, it is a very difficult dialogue. If a patient doesn't understand what I want to tell him, he may make decisions based on his intuition and increase the likelihood of a bad outcome. As far as the doctor-patient relationship is concerned, the problem is rarely the physician's negligence or incompetence (although that might be the case, of course). That is not the problem. The problem has to do with communication. In 80% of the cases it has to do with communication. The doctor-patient relationship is an unequal relationship: we have access to information that patients don't have, so our obligation is to try to communicate as best we can with them. On the other hand, we have to accept the degree of uncertainty of biological phenomena, which means that we never know what will happen: for example, one study tells me that a given medication had a given effect in the 5,000 patients who took it, so I expect my patients to respond to the treatment in the same way, but sometimes they don't. That uncertainty also affects our relationship with our patients. We are always looking for certainties and most patients don't understand that they don't exist. And the real reason why patients choose doctors is rather curious...
What is the real reason?
Reputation, which seems logical. But how do physicians earn that reputation? Who is the most reliable source of physician reputation?
Who?
Let's start by considering the problem: one of the ways of assessing a physician's real reputation would be to ask his patients directly. There are several studies on this carried out in England, Canada, the United States, based on an assessment aimed at defining - from the patient's perspective - what clinical competence is. But these studies showed that there is often no relation between medical proficiency and the individual physician's reputation...
In your view, should this recognition also be based on the opinion of peers?
Exactly. Professional peer review is very important. That's what physicians do in the U.S.A. Every year the New York Times publishes a list where it asks, for example, 100 pneumologists, or 100 paediatricians, or 100 cardiologists, who are the top 3 physicians working in their specialty in NY. The final ranking is very helpful for patients, as it gives them the opinion of peers about individual physicians. For example, when one of my patients asks me to recommend an ophthalmologist, I refer him to a colleague whom I trust, whom I know and with whom I have already worked. Why isn't this valuable information made public? (I can see some people getting nervous about this suggestion already...) (Laughs).
Following your constant references to the United States: We had the opportunity to take a look at your academic/professional career and we realized that you spent some time attending both academic and professional training abroad. It seems like the United States have indeed left a mark in your curriculum. Would you like to share with us how the opportunity came along for you to study and work in the U.S.A.?
It's a long story...
How does it start?
The Revolution of April 25, 1974 happened when I was in the 4th year...
Here at the Faculty?
Yes. Well, the revolution destroyed the course; there were no classes that year, no exams, everyone passed. In the 5th year, the exams took place around a table; the assistant asked each student a question and everyone got the same grade. In the 6th year the exams became a little stricter, but you were only given a "Pass" or "Fail ". There were no grades. So, I spent the following years turning the "Passes" and "Fails" into "16s", "14s". Well, what matters here is that I got to the 6th year and I realized that I didn't know much about Medicine. I thought to myself: "I'd better go somewhere where I can learn!" And what was the best place at the time? America. The exams to go to America were very difficult. Only a minority of applicants were accepted. So, I decided I also had to take exams to go to the United Kingdom. In that way, I would kill two birds with one stone: if I failed the exams to go to the USA, I could always go to England. For about four years I studied and took sequential exams, and when all that was over I had passed both the American exams and the English exams. All I had to do was choose. And I chose the United States. The United States were (and that hasn't changed to this day) the "place" for Medicine.
But, you didn't go alone...
No. I went with two friends, who ended up staying longer than I did. I spent several years in New York and San Francisco. After some time, I realized that I didn't want to stay there.
Why?
Because I had no interest in that society. I was never an immigrant. My idea was to go and come back. But, I wasn't interested in living in America. It was an extremely creative society, like no other, a fabulous place to work (the conditions!) but the social style, the structure... Also, my parents were getting old and I felt I had to take responsibility and come back to assist them. I never hesitated and I never regretted it. It was a deliberate decision.
With regard to this American mindset, stemming from your training, was it the main driver of your interest in Evidence-Based Medicine?
Yes. When a patient was admitted, for example, at the hospital where I worked in New York, there were no electronic files, it was all paper files. It often happened that when patient was hospitalized, there was a medical article in his file, which was relevant to that particular case. So there was always someone concerned with providing scientific foundations to underpin what we were doing for the patient. I made a habit of reading all the articles relevant to each specific case. That's when I realized the extraordinary importance of clinical science as basis for decision-making. Things have been developing in this direction. So that's what made me shift my mindset towards medical education based on scientific evidence, partly because everything is being studied nowadays: patients, diseases, the health system, diagnostic interventions, prognosis... Nowadays it's very difficult to say that we have no information when faced with a clinical question. The question is: Where is this information? Where do I find it? In which database? And then I have to ask whether what I have in my hands is any good! That is what Evidence-Based Medicine has brought us. If the study is good, I'll keep it. If it's not good, I'll trash it. So, this has radically transformed clinical practice.
Even supported by evidence-based studies, you sometimes pass on messages that are somewhat divisive in the field of Medicine, which can prompt a reaction from some of your colleagues in the profession. How do you deal with opinions that differ from your own?
I think I have an advantage: the methodology I use protects me from judgements on intentions. I always try to justify everything. To contradict what I say, people have to use a methodology identical to the one I used: clinical science. Otherwise, there can be no discussion. My opinion may be irrelevant for other people, but when I have to express it, I like to define it and substantiate it in a transparent and explicit way. If people read what I read and interpret it as I did, they will reach the same conclusion. But there have been discussions where I had to admit a defeat: "- You may be right. That's a better interpretation of the study!" The scientific methodology is the only one I recognize as basis to support decision-making. If anyone wants to show me another one and compare them, I will be open to that discussion, but that has never happened to this day. I know that antibiotics don't treat cancer, or that an antidiarrhoeal doesn't treat a headache. I have studies that tell me what one thing and the other are for. These things are right in front of our eyes. Either the study is not good or it is and, in that case, we can't ignore it, otherwise patients will be the ones who suffer. This strictly scientific evidence should be added to the physician's clinical experience, which is a very important source of information, because it captures a reality that clinical science can't capture: for example, my elderly patients always have at least 4-5 diseases. There are no studies in patients with this number of comorbidities.
Professor, not wanting to look too deep into your professional decisions, but trying to understand better some of your options, why did you start dedicating less time to your clinical practice?
It was not an easy decision. I greatly diminished my clinical activity because I didn't have time to do everything. I got to the point where I had to make a choice because I felt that I was risking not doing things properly in either area (clinical and academic). In the USA I trained intensely to become a doctor and when I returned, I brought the American standards with me, that was the model I wanted to follow. The problem is that the way the system was organized didn't allow me to do both things at the same time - the so-called academic medicine - as intensely as I wanted to. In America you can do that; in Portugal it's a lot harder, but the situation is improving. When I was spending 50 or 60 hours at the hospital, I had little time left for academic work, especially because I had one or two 24-hour emergency shifts every week... When I got home I didn't want to think about Science. So it was a complicated, but very natural, decision.
We usually see you speeding up along the corridors of the Central or the Egas Moniz Building, how long does your day really last? How do you organize yourself?
First of all, because this is my nature; secondly because I really like what I do, and that is why I, sometimes, I take up huge amounts of work that people usually don't accept. But I only take up work that I find important, not tasks that would pointlessly consume me. I'm very organized: every day I study for 1 hour, from 8 to 9 am, using articles and studies I selected from the top 12 journals in the area of Internal Medicine over the course of the previous weekend (I scan the articles and save those that have to be read soon and those that can go to my personal information system, which contains thousands of pdfs, duly classified for easy access). I have time to play tennis twice a week and every day I have dinner at home with my children and my wife; despite working 12 hours a day, I always do this.
As far as the Faculty is concerned, what do you consider as your greatest achievement?
The creation of the Centre for Evidence-Based Medicine (CEMBE). The CEMBE is the only one of its kind in Portugal and one of the major European centres in this area.
Professor, how can you reconcile teaching with research and management and the various positions you currently hold in our Institution?
First of all, and as I've mentioned, I try to be extremely organized, that's the only way to be able to respond to most challenges. Sometimes there are complicated moments, but there is always a way to work around them. But, yes. It's very difficult to turn down an invitation, especially when it comes from the Institution I work for, because I assume that when the Institution asks me something, it's because it has already analysed the alternatives. It's very hard to say no in these cases. On the other hand, I need to be constantly thinking and creating things, that's what gives me pleasure. And things are going well because I work with an exceptional group of people and it's only fair to recognize that without them (in the CEMBE, the IMP, the IFA, the AIDFM, etc.) nothing would be possible. I'm very pleased and honoured to work with world-class teams like the ones I have at the FMUL. That's what justifies my existence in the professional field.
Isabel C. Varela
Editorial Team