News Report / Profile
"How Long - A Child in his Eyes"
The title is not mine, but during the time I almost limited myself to listening to and observing him, I couldn't stop thinking that I had to use it. I borrow it from the journalist Luís Osório who used it to name the book he wrote to his father, whom he lost too soon.
On the table he has the medical records of 5 of his patients, whom he knowns rather well and will see during the afternoon. At 93, Carlos Ribeiro is still seeing patients in his private office in the heart of Lisbon, in Saldanha. He sees them every Friday, thus maintaining the link with patients he has known for decades.
He says that he'll spend an hour with each of them. "These patients are my friends, they don't come just to talk about health. They come to talk about their concerns and how they influence their health". He tells me about the importance of having a thorough knowledge of patients because it allows absorbing their families' history as well. And in the case of a patient with heart disease, the family is also sick, he explains, because "to treat the patient's pathology we often have to treat the family's pathology". Being an acute disease, "myocardial infarction should be seen as a chronic and familial disease, shared by all and for which discipline or protection are never enough", he says. But knowing the patient is also knowing his workplace environment history, or even his relationship with his favourite club.
It's precisely the heart that he's been saving and treating, since 1972.
Although people say that there's always a moment when an excellent apprentice becomes the master, Carlos Ribeiro, Arsénio Cordeiro's apprentice, still sees himself as the latter, not as a master. But let's tell the story as it actually happened.
From humble origins, his father worked in the cork industry and his grandfather had been a fisherman, while his mother's family was involved in agriculture. Carlos Ribeiro knew he was not privileged and that he would have to fight to get life to give him something in return.
When he was a child he studied in his home town, Seixal, but he quickly decided to come to Lisbon to pursue his studies, attending the Passos Manuel High School and finishing his academic career at the Faculty of Medicine, then located at Campo Santana.
When the time came for him to enrol for the compulsory military service, he considered applying for a position as military physician, earning a comfortable salary that would help him manage his life and finance his post-graduate studies.
It was Arsénio Cordeiro, founder of the UTIC (Coronary Intensive Care Unit), Professor and Cardiologist, who deterred him from pursuing a military career, telling him that he would be sent to various parts of the country, losing his connection to the Santa Maria Hospital. He then suggested that, if he needed to raise money, he should work in his home town. So, Carlos Ribeiro spent his mornings at Santa Maria and saw patients at night at his "rural practice", as he calls it, "starting from the bottom". Called Dr. Carlos by all those who surrounded him, even his childhood friends, he knew and had contact with all types of clinical realities, acknowledging that Paediatrics is the one that concerns him the most, even today. He recalls, with a great sense of respect, the effort that the most humble families made to receive him at home, depriving themselves of their own comfort to provide it to the "doctor". He tells me that starting without privileges was a blessing because it had taught him how to do everything and to value his achievements.
He specialised in Cardiology, observing his master Arsénio Cordeiro, while he refined a sophisticated technique. He soon realised that the same disease had to be treated differently depending on the patient, and that it was important to know how to look at him, to give him time. He tells me that "the circumstances of a given patient are very difficult to explain to another one" and compares this to ethics, which he also tells me that cannot be explained, "it is taught by example by a generation, and not exclusively passed on in courses".
He recalls the time when he was Chairman of the Medical Association and refers to this period as being somewhat painful because his ethics never allowed him to accept or understand the balance of forces between doctors and pharmaceutical companies and their hypothetical relationships.
He let me talk to him about almost everything, he only didn't pay much attention when I mentioned the 20 he got in his PhD thesis, in front of his Professor Arsénio Cordeiro. Nor did he value the revolution he led in the UTIC, where he facilitated the creation of a database with 6000 patients and systematised all the clinical parameters, mapping the exact profile of myocardial infarction, from diagnosis to treatment.
He internationalised the UTIC thanks to a large number of research articles published in national and foreign scientific journals and suggested the implementation of Nuclear Medicine, Hemorheology, Echo, Ergometric Tests, Holter Registers, and Hemodynamics for diagnosing myocardial infarction. But he didn't want to talk about this in detail.
Attentive and speaking slowly, carefully dressed down to the last detail, he talked about so many other subjects that, for the first time, I was not able to retain a single detail of everything that surrounded him, except for his gaze and his full head of white hair.
He explained that the heart is an organ stimulated by electricity that comes from the central nervous system and has a battery of its own that continues beating even when it's outside the body. A gifted organ, he says, smiling, "the heart found in poets the protagonists that have overburdened Cardiology, because they refer to it as the centre of feelings". But he also talked about feelings with emotion and explained that as a physician you can't show fear or fragility in the presence of patients, those emotions should be kept in the private sphere. But he gets emotional, and always has, with everything that involves children.
He's a family man, and that explains his 7 children and 16 grandchildren. He loves talking to his grandchildren and says he has always tried to listen to the younger ones.
At the age of 93, we could calmly say that the Professor, the master, has already reached the peak of his wisdom, but he warns me against the danger of thinking this way, since "error is crucial for growing and those who think they are never wrong are dangerous".
From so many points where to start, perhaps the one that stands out as the most important is how he has always looked at patients. At a time when artificial intelligence is being so widely discussed, where does this leave the relationship with patients?
Carlos Ribeiro: Everything suggests that there will be less and less dialogue. Patients are becoming increasingly excited about medical tests. They get really excited when they see an ultrasound or a colour isotope scan. The complexity of Holter registers also excites them. They look with the same enthusiasm at figures in their analyses and are pleased when cholesterol is close to the average indicated in the result sheet. They have a tendency to suggest new medical tests and, sometimes, they go to appointments only to have doctors request them. On the other hand, life is getting faster and faster and a classical medical act takes longer than requesting these medical tests. The patient is pleased and the doctor meets the requirements of the Administration, shortening the appointment. In some cases, first appointments are scheduled to last 15 minutes... And I ask, "what can we do in 15 minutes, when people are not even given enough time to make a proper complaint?" I often see people who come to me with piles of exams and they only ask for my opinion regarding the documents they bring in. I take those exams and place them here behind me. (He points to a small cabinet with drawers and shelves). And I always say "you are the one coming to see me, not your exams, so what is your problem".
Medicine is now almost robotic, isn't it?
Carlos Ribeiro: That would actually be more convenient. A robot doesn't get tired, its mood doesn't change, its conditions are always the same. For that type of Medicine a robot is more useful. A doctor has the disadvantage of not behaving as precisely as a computer. That's why I wrote the book - Being a Doctor - where I argued that we have to go back to treating patients and not diseases, to look at patients and their circumstances. There are no personal myocardial infarctions, but rather familial myocardial infarctions. When a patient has a heart attack, the family starts interacting with the patient in a completely different way. He starts being overprotected and either he likes it and takes advantage of the situation, or he feels like he's being treated like an old man, or a child and doesn't like it.
Has your heart ever betrayed you?
Carlos Ribeiro: Me? Never! I've never been sick.
Carlos Ribeiro: I had my tonsils removed at 27 and had a few colds. However, even with a fever of 40º I didn't stop working. Those who work with me think that I'm not very understanding because I never believed that they were really sick. (laughs)
And was it true? Did you really believe that?
Carlos Ribeiro: I asked one of my employees not to kill more aunts, because she was always going to some aunt's funeral. (Laughs). We physicians get viruses much earlier than the population in general. We have to be aware of that.
But that is being sick!
Carlos Ribeiro: No, it's not. Being sick is something that prevents us from taking action and going out. I never had any of that.
In the ceremony of the 50th anniversary of the UTIC I noticed that there was not a single person that didn't greet you on their way in, always paying some kind of tribute. The video that was screened was also a tribute to your work at the UTIC. We only need to read a few papers and listen to people talking about you to know that you are a major reference. How do you feel about all this?
Carlos Ribeiro: Lucky. It's a matter of luck. I was lucky to be born into the family I did, in the city where I did, to make the friends I made from primary school to high school and university. I was lucky to choose the profession I chose. When someone likes his profession so much that he would pay to work...that's luck! (smiles happily)
When did you realise you had a passion for Cardiology?
Carlos Ribeiro: I loved math and I always got the highest marks. When I was in the 7th grade, I actually hesitated between Medicine or Mathematics. But I thought that the latter would isolate me from the community and I liked to interact with people, so I decided to study Medicine. Then, during the course, I had the opportunity to attend the class taught by Professor Arsénio Cordeiro and I followed his career since the 4th year of my degree. In the 5th year, every time I had free time in my Hospital schedule, I went to meet him and his Assistants... (Smiles and thinks) Because he was indeed an extraordinary man.
Was Professor Arsénio receptive to students?
Carlos Ribeiro: Oh, yes! He liked to be asked questions and he liked to talk and explain, to create...and he was thrilled by that! So, he loved all curious students. He was the right man at a time when there was no internet. He was our internet, we asked him questions and he answered. So, don't tell me that I wasn't lucky to have met this man! I could have ended up in a different class, a different group. Professor Arsénio Cordeiro was the best asset in my curriculum.
All I did after that was trying to imitate him, if such a thing is possible...
And I would often look at a patient and ask myself, "what would Professor Arsénio do?".
Do you still do that?
Carlos Ribeiro: I used to do it; I no longer feel that need, but I did it for many years. And I asked myself how the Professor would react in a given situation.
We need to have examples to point us in the right direction, don't we?
Carlos Ribeiro: That question reminds me of the story of an Italian Pope; when he was still a Bishop in Italy and there was a big problem in his jurisdiction he would always say "I'll talk to the Pope". The problem is that, at a certain point, he was elected Pope. One day, faced with big problem once again, he thought "I'll sleep on it and tomorrow I'll talk to the Pope". (Laughs) Then suddenly he said, "wait, but I'm the Pope now!". It's always good to think that there's someone to whom we can ask an important question, even if that person is no longer with us. That person is our Pope.
Talking about examples, you were the representative of the current Chairman of the Medical Association...
Carlos Ribeiro: He's a very active person and the program he showed me was very appealing. In fact, by supporting him, I went back to dealing with the problem of the Medical Association. Because as soon as I left the Association, and I was only there for 3 years, I never wanted to get involved in anything that had to do with the institution again. But when I was introduced to this Chairman, I decided to support him right away. I believe that when we leave an institution we should never go back.
Carlos Ribeiro: Because if we go back just to show up and give our opinion, we're only going to upset those who are there. Because we know about competencies and intricacies and we can tear the other person's ideas apart and maybe they're good ideas. When your term of office is over, you should leave. Speaking just for the sake of speaking and interfering with institutional politics only causes damage. And it's the Institution that matters! So, I tell you that you should never go back to a place where you have been happy.
Everything has its time... Does time scare you?
Carlos Ribeiro: When we get old, time goes by differently; for us, time is almost repetitive and days are almost identical.
Do days lose their magic?
Carlos Ribeiro: No, they're just identical. In the past, Monday was different from Thursday. I could only sleep in on Sundays. Nowadays they're all similar, because I can sleep the same number of hours every day, take the same time to write and read, the same time to talk. I have one social gathering or another... One thing I've learned with age is that the passing of time is less noticeable, because time is homogeneous. I've already done some calculations, "my father lived until he was 85, my mother too...", but then it was by 85th birthday and I thought, "well, let's carry on".
Do you do those calculations, sometimes?
Carlos Ribeiro: Yes. I was born in 1926 and the limit was 2016, well... it's gone. Now we're going for an even number, 2020. (Stops calmly and doesn't look at me) Living is very good. Living is very good. Even if it's sitting down. It's already difficult for me to walk, but I'm happy just sitting down. There are so many culturally interesting things for one to do. From watching Mezzo (classical music channel) or RTP2. So many things... Sometimes I can visit friends like Eça or Camilo, but also, among others, Pessoa. (Thinks calmly). There are so many interesting things. Then there is a problem with a patient/relative and we have to read to update our scientific knowledge. Understanding the course of science is a beautiful way to pass time without noticing it. Even in Quantum Theory, time is not as important as in Euclidean Mathematics, which considered the existence of four planes: upper, lower , natural and time. In Quantum Theory, there are 12 or 24 planes and then you have to work on them. Time is diluted. Think of the black hole, it marks the end of time and space. And if we're expanding the Universe, that influences time. So what is time? (Pauses) Then there is another important concept we should understand. What is life? We physicians are interested in mass, but in Einstein's theory, energy is equal to mass multiplied by the square of the speed of light (E=mc²), so our mass is minimal if we compare it to the energy we have. One person has enough energy to light up a city.
Professor, what remains to be said about you that hasn't been said yet?
Carlos Ribeiro: I think that too much has been said but... (stays silent for a while, at peace) I think that there's not enough emphasis on the fact that I'm a lucky person. I'm only unlucky at play, I'm from Sporting. (Laughs).
During our conversation, I often got emotional listening to Professor Carlos Ribeiro. Like opening an old book that transports us to the history of things, listening to the Professor is like a real-time account of the past that transports itself to the future. It's like a shot of energy that will keep beating, like a heart, even after leaving the body behind.
How much longer will we be able to speak to the Pope or the master who will leave us one day?
For as long as our memory will let us.
Acknowledgments - To Vasco and Lourenço Ribeiro Tamen (Grandchildren) who did an excellent biographical work on the grandfather and ended up helping me even without knowing each other.