News Report / Profile
Rui Tato Marinho - 30 years curing people with Hepatitis C
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For taking on the Presidency of the Portuguese Society of Gastroenterology last May and for his prestigious record as Director of the Gastroenterology and Haepatology Department at Santa Maria Hospital, we had organised a forthcoming uninterrupted conversation.
Rui Tato Marinho is an Associate Professor with Aggregation and an integral part of the Pedagogical Council of the University of Lisbon's Faculty of Medicine (FMUL). A Gastroenterologist with a sub-speciality in Haepatology, he is familiar with the international roles of scientific societies, considering them, in fact, to be a vital attribute for being a good leader and a good manager of people and their emotions.
We formally met at a meeting discussing the first ideas from a round of conversations that he would initiate and whose topic could not escape him, "Hepatitis C and its future." At this meeting with various elements, I noticed his lack of asserting himself, or trying to stand out. He instead allowed others to speak and patiently accepted them, as if he were always in some sort of clinic, where he observed without expecting any personal affirmation.
Often the bearer of bad news, he has become accustomed to not judging anyone for their clinical status, and to trying to decipher the paths in life that each person takes. He thus views them to see how to cure them, without resorting to judging if the paths they chose led them to a better or worse place. This curative attitude towards others is perhaps due to him being the son and grandson of judges of the Supreme Court of Justice. His family, who have always defended him and taught him this logical drive of Justice, ensured Rui Tato Marinho believed in humanity in a very hopeful way. "People need to be rehabilitated and integrated into society. Putting someone in prison is very bad, though sometimes necessary in the name of national security. However, society needs to know how to forgive, because these people have to try to get better. We must fix this: society has only to gain if it helps drug users and integrates them into civil society. Through treating them and curing Hepatitis C cases, they feel happy. And do you know what follows? They commit less crimes and not rarely are they thankful, with a renewed will to cooperate with the society that has invested in them and forgiven them."
Medicine doesn't stop, however, being at the root of life for him. He says that a great influence to his academic background was his wife Luísa, one year older than her beloved Rui; she enrolled at FMUL and he at Campo Santana. There he completed his entire study programme, and shortly afterwards he applied for the "big city full of light," also known as Santa Maria Hospital, with the University campus he so admired. The other big benchmark would be his uncle Tomé (Prof. Tomé Ribeiro), who was already a doctor, Professor, and Director of the Gastroenterology Department at São João Hospital, Porto. It was his uncle's speciality that would have certainly influenced his own clinical choice. Very close friends of his uncle, Professors Carneiro Moura and Pinto Correia, were waiting in Lisbon for the recent Medicine graduate Rui, who was already very openly saying that he was "going to a jungle, but [he was] unafraid."
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He tells me about his uncle's house, in Maia, made by architect Siza Vieira, as an example of subliminal messages that are even more valuable now. An example of this is its small dining room, with no space to fit a television, which had a round wooden table where a maximum of 6 people could fit, but in truth it was almost always 4. At this table, at lunch or at dinner, the Family would get together to spend time talking about life, responsibilities, gaining empathy from one another which was intended to teach and communicate between generations. He taught what he learnt from those times to his two children, João Pedro and Margarida, now grown up and independent, with a grandson, Duarte, already born and another, Francisco, on the way. The round table was the basic principle of dialogue and learning; it was a priority for the four. It is from this "table principle" where the values that the Professor always made a point of discussing were taught and later reinforced, such as loyalty in relationships, marriage, and to the person with whom you choose to take this journey side by side and that without this there is not the same structure or the same personal growth.
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He talks with a calm tone of voice, without vanity, without the faintest hint of fake selflessness, like something that characterises good people, which is always said about heroes, so distracted that they aren't even saying it. Rui Tato Marinho is not a hero or God, that is true, "but he plays the role of God on Earth very well," says one of his (Friends) patients to him once.
I have also been told that he volunteers and when he was told what was ahead of him, he barely reacted, just lifting his head up and said it was "nonsense because there are some days where nothing happens." After a few seconds of silence he concluded, "What doesn't make sense is us walking in this world without noticing others; we all have to do something for one another."
Rui Tato Marinho was an athlete for Benfica who still likes running today. He tells me that it's "great for releasing endorphins, coming up with ideas and is therefore a natural anti-depressive" and despite not being as susceptible to depressive episodes, he likes using his body so that chemically he makes himself feel good. A discipline, sport, that was also passed onto him by his father. Since he was little he wanted to get him practising Judo: "it's good because you learn to have self-control." After doing various activities, at 15 he was running at speed for Benfica, always pushing himself out of his comfort zone and, as important as studying, sport taught him to know when to lose and when to feel pain, "because as better as someone may be, they are never the best and learning to compete with ourselves, creating our own objectives, though it is immensely painful, psychologically makes us resilient. Another example of discipline and resilience was inspired by his mother, who had 4 children, 3 boys and a girl.
He has clear eyes. I'm unsure whether they're blue, green, but they alone don't prejudge or expose any personality of their protagonist; they are deep and loyal to their immense description.
Even in this way and unceremoniously I managed for us to have a very honest conversation, as if I were one of the many people he had already known relatively well and he were here to see how I was. He, the Professor, also thinks it's important for people to know each other and let themselves be known. And this didn't take away his prestige, respect, or break some ever-necessary balance of formality, but it is in the story of another that we learn to respect them more. Therefore, he gets all his residents to do a small introduction, where they talk about themselves for a couple of minutes. "People like talking about themselves and it is very important to know what is there behind that person," he says always emphasising the human side that to him is so obvious, equal to what he has with his patients.
He describes his profession as one of the most humanly rich, on the same day where he, truthfully, receives a priest, a policeman, a minister, a lawyer, a criminal police inspector, a housekeeper, a judge, a prisoner, and a prostitute. I tell him about the range of social groups that enter through the Santa Maria clinic, because he only works there as a doctor, and from there the conversation becomes delightful...
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People enter here from a society that is completely uneven...
Rui T. Marinho: And the liver makes it completely possible to analyse this. (liver diseases don't choose social strata, poor or rich)
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Why is the liver our internal citizen card? And who talks the most about us?
Rui T. Marinho: It's one of them because it says a lot about people's behaviours . What we've done says a lot about us. I deal with alcoholics, drug users, patients with obesity, in other words, I deal with personalities with addictive behaviours.
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And is there a big difference between a patient in the public sector and one in the private sector?
Rui T. Marinho: I opted for the former, I only work in the public sector. I still treat a lot of such patients, but even many from the so-called upper classes. People from more than 45 countries.
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Why?
Rui T. Marinho: There are excellent doctors in the private sector, but I have always had the idea that you had to serve a lord. Running from one place to the other doesn't suit me. But if one day I decide to switch to the private sector, I'll keep my principles, refusing to be rushed off my feet. As I've always done for the past 30 years... there are some things that I am very proud of. It's like a marriage where the couple get along well and manage to make things work. And besides, I really like this type of university hospital with a model that is very much its own, we have here some of the best colleagues in the country with impressive CVs on a European level.
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You mentioned that your uncle was a doctor some time ago, and I started wondering whether a certain patient-doctor agreement would have been lost?
Rui T. Marinho: This relationship isn't the same as it was in the past, this is both good and bad. In the past you had both extremes: doctors either knew every intimate detail or they didn't even allow the patient to ask questions, because they knew everything and couldn't be questioned. Communication was poor as they would use technical terms a lot.
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And which extreme do we occupy now, on the whole?
Rui T. Marinho: I think the two extremes still exist, only with subtle differences. The vast majority of doctors I know are both good doctors and human beings, and really like their profession mainly for the human relationship with their patient and the will to help them. Emphasis of course on "vast majority," since as in all professions there are different people. Today, the barrier that was previously silence, where the cancer patient was the last person to know, has changed. We're obliged to look someone in the eyes, be the bearer of bad news and explain everything, especially because the patient is much better informed, uses the internet and at times is even already more informed about a certain topic.
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Does a doctor have an obligation to tell the patient everything or only as much as they want to hear?
Rui T. Marinho: I'm prepared in giving someone bad news, I was asked to train anaesthetists on this 10 years ago and I had to read a lot about this subject. It's not enough to know a lot about a human being; we need to know how to give someone bad news. Noticing if the patient is crying or not, if we look them in the eyes and what they themselves tell us. As it happens, Medicine study programmes should offer more practical training in this area. Did you know there are days when I arrive home after having had to tell 2 or 3 patients they had cancer... People aren't all the same and every person is a puzzle; consequently, how we tell people information is different for each client. It further depends on the doctor's own sensitivity. I remember hearing about the 5 stages of dying...
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I don't know them.
Rui T. Marinho: First they try to deny the bad news, then comes anger, followed by them trying to fight against the diagnosis, then depression and ending with acceptance. And I can identify my patients in any of these stages. Dealing with different personalities, my concern as a medic is, therefore, that the person there in front of me knows what they have. And knowing what they have, they don't need to hear "you have cancer." In fact, I don't like anything about that word, and I rarely use it. Telling someone bad news can take 3 or 4 seconds; it's enough to say something like "there's a small mass here in the scan that concerns me and needs more examination." And of course the next question is if it's bad news, to which I tell them that it could be. The news is given and the patient is soon able to understand what's happening. I use this technique whether my patient's a minister, or illiterate, I treat both and they both understand.
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Is the patient's status completely irrelevant for you when it comes to the disease?
Rui T. Marinho: It's done in the same way, but maybe with different language, but even someone who can't read or write can understand what's happening to them. We have to explain ourselves so that anyone can understand us, and communication isn't hard. Do you want a good example? Professor Marcelo R. de Sousa has a very advanced scientific level but can make himself understood to anyone.
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We've talked about giving bad news, but can this news also have a positive outcome sometimes, or not?
Rui T. Marinho: Sometimes very positive. I have had highly poignant experiences because I have patients here who have already gone through a lot in their lives, successive problems that pass us by and nonetheless the recognition they have for their doctors is something that is very worthwhile. They are some of the best "friends" I have made here in the way that I have treated them medically. Most of them have taken drugs or have been arrested. They would come to my house to repay me, and not just monetarily; one of them was a taxi driver for my children when they were teenagers, a lot of times he'd even work throughout the night. I believed in him, despite him having been arrested. That recompense from another is indescribable.
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Are you talking about gratitude?
Rui T. Marinho: Pure gratitude. Some of my richest patients, though fewer in number, have expressed such gratitude.
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Gratitude comes from a public that is also particularly fragile socially...
Rui T. Marinho: Undoubtedly, but we also have aggressiveness, yet that comes from Social Media and which involves concerns such as medical negligence, crisis and lack of conditions that interfere with our actions; that's what sells. And this entails a curious phenomenon where people like their doctor, but don't admire their class. Some find us arrogant. We have to learn humility.
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Is that label a myth that has been created or do we in fact have a class that is full of themselves?
Rui T. Marinho: Yes... there are vain doctors. (He sniffs as if he is calculating his words, he then thinks a bit). We should work on our non-scientific performance more. Portugal has very good medical teaching, with exceptional medical schools, but the emotional aspect and emotional intelligence should be worked on more. We can learn from fields like Marketing, Journalism or Communication, to have more effective human relationships.
I'll give you an example of the TAP pilots…
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It's funny you mention them, because you've anticipated my next question which was precisely why do you tell so many pilot analogies talking about medicine...
Rui T. Marinho: TAP pilots have a very good image, yet make as many mistakes as us, and are as old as us. And they are a group with which I have maintained a great relationship and one of them some time ago was telling me, "we're doing training about humility." Do you know why? Because they learn to make less mistakes, ask, have doubts, work in teams, all of which means less mistakes. There are planes that have crashed because the pilot didn't want to listen to the opinion of his co-pilot who, for all intents and purposes, is not in the same rank. I think that we also needed lessons in humility. Note that it isn't "just a little bit of humility;" it's what enables us to listen to others, where everyone in a department, from the cleaning lady, to the most aggressive patient, are important. It is also important to accept when we don't know and admit that we're wrong, asking for feedback from someone who knows more. All of this is part of being humble. And with aviation being the safest human activity it can offer us more lessons, even learning through simulation.
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In what way are pilots and doctors related?
Rui T. Marinho: Aviation is seen as the paragon of human safety. Notice that a commercial plane hasn't crashed in Lisbon for about 30 years. There was one year where not a single plane in the whole world crashed and note that millions fly each year. And why? Because they are very safe and, with some differences, it's the field that, like us, deals with the human factor and the safest systems around. Simulation, for example, is something that we can learn from aviation. Simulation is very much taking the lead in Medicine. We're going to have a very major simulation centre, which will give us a sense of teamwork and feedback, which helps us a lot. I have visited many pilot training centres, specifically about security, and I have been dealing a lot with them. We can learn a lot from them. Note that: an hour before they fly they meet to check the flight time and path, they have check lists all of which the pilot and co-pilot have to review, followed by a further debrief to evaluate their work. Do you now see that this is also important in the world of Medicine? Listening, receiving feedback and learning to communicate with others? If we look more and do more, this parallel also guarantees us better safety. Did you know that a TAP captain is the same age as me, (says smiling) and he has reached a popular status and I'm easily accused of negligence. I've done 25,000 emergency hours and a pilot at my age has done 17,000 flight hours. We are people from different worlds, but what we want is others' safety, to do the best job we can and not mess up.
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Do you think that as a doctor you're viewed with little admiration by society?
Rui T. Marinho: Us doctors are often poorly viewed, clearly influenced by Social Media. But also because it's our fault, for not investing enough in good human communication. In many of the emergency hours that I've done, I've often been insulted without them knowing me because the person was already angry with the system and with what they heard. There have been colleagues of mine who have ended up being assaulted.
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Someone as dutiful for their patient's safety, who has their methods and knows that there's an effective formula for a treatment plan against Hepatitis C, still loses patients with that very plan that, apparently, shows results that would save them. And this is because the treatment plan arrives too late, because there isn't funding for everyone. I read in the book "Hepatitis C - The Future Started Here" the former Health Minister, Adalberto Campos Fernandes said something like, "Portugal can put an end to this Hepatitis epidemic by 2030." Can they?
Rui T. Marinho: Medically I don't think it's doable. The Hepatitis B vaccine has already been talked about for many years, and that was going to put an end to the disease worldwide, but it hasn't, not even in Portugal. As they're chronic diseases, some Hepatitis C patients already have cirrhosis and thus have a risk of liver cancer despite the virus being eradicated. But we can significantly reduce it in terms of its impact on public health. Treatment in certain hospitals is currently very difficult to achieve. There aren't patients who are left untreated, but they end up waiting months.
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And this waiting time can be detrimental to their life expectancy, no?
Rui T. Marinho: In 6 months no one would die because of that wait, but they will have a higher risk of liver cancer if they have cirrhosis and some people despair and subsequently abandon treatment.
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If I understand correctly, even if someone is cured of Hepatitis C, if they have cirrhosis, they can get liver cancer and die. So they're not cured.
Rui T. Marinho: But the risk is immensely reduced.
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While we were talking, you told me that you weren't afraid of the field you chose to work in and that even with the risk, it didn't shake you. Aren't you afraid at all?
Rui T. Marinho: No. I wasn't when I started. Nor am I now. Of course there are threats, situations that arise where we know they could involve risk, but we know that someone has to take them on.
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Let me ask you a question with no intent in provoking you. Seeing your CV and the responsibilities you currently take on directing such strong entities like SPG and the SMH Gastroenterology Unit, why don't you have the University Clinical Chair in the same area in the Faculty?
Rui T. Marinho: That I don’t know because they are choices for who's in charge and that I respect. There was once a time when the head of the Department was Director of both boards, but that has changed. With all due respect, I think that the complexity of my board is so great, and being responsible for a chair is also a complicated task that requires a lot of our time and commitment. In recent years we have increased 500% just in endoscopies. I therefore understand why they are different people, especially since they would have some problems with time management to accumulate both things. And I think that this chair is very well entrusted with Professor Helena Cortez Pinto.
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Pertaining to your presidency at the Portuguese Society of Gastroenterology what are your main objectives?
Rui T. Marinho: Above all, thinking about our patients. The one suffering has to always be at the centre of everything. Furthermore, I want them to receive trustworthy, scientific information. On the other hand, I want to explain to society what a Gastro... which already has a complicated name, does, and I want to try to boost it to the social scene. If people understand well the role of such a doctor, they will also understand the diseases much better and how we can help patients. We need to improve the social perception of a doctor. The gastroenterologist is frequently pivotal. We can't forget that 3 of the 10 most fatal diseases in Portugal and a third of cancers affect the digestive system.
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Explain what you were saying with such pride about knowing how to keep a marriage together after 30 years?
Rui T. Marinho: Because things have to be very dynamic, it's a process where people are growing, life is different, and then come the kids, followed by the speciality that we want to follow, then the kids start school and then nothing is monotonous. The difficulties come from everywhere and we need to have a very extensive emotional resistance. And this resistance, this emotional intelligence is being learned and is being worked on. I did a management course with my wife in 2002, I owe this to the Faculty, you can't imagine how this training completely changed our way of viewing things.
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Let's go back to your uncle's round table... Do you regularly see your family?
Rui T. Marinho: Well it's more difficult with João as he works in Brussels as a European lawyer, I see Margarida every week, she's an economist at the Bank of Portugal. But 3 or 4 times a year we all come together.
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It's not a lot... Professor...
Rui T. Marinho: True, but more isn't feasible... we say every week, but... (his voice quietens as if someone had turned down the volume on the radio) in life this is a fixed-term contract. We have children up to a certain age. Besides, what matters is that they're happy and doing okay. But I talk with them and they teach me so much, give me lessons in their areas and the experience they've acquired, and they enrich me.
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As a Professor and doctor, are you going to visit your liver and ask it if it's well?
Rui T. Marinho: Of course! I've already had my necessary analyses. And exams. Since I was 50, once a year I make these visits to myself and I try to take care of myself, not put on weight, not drink too much. But I know that as we get older there's something waiting for us. We're all going to die, it's just a question of when. The later, the better. But there's a day that we know we are. And I know that, as I have lived, 40 or 50 years more and I won't be living the same time anymore. So I take advantage of life and happy moments a lot more now and little things are enough for me: a happy interview, lunch, the pretty colour of a room, music.
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Death doesn't worry you?
Rui T. Marinho: No! But I'd like to be here in 20 or so years to savour even more things in life.
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To every question I asked he responded without any look of being upset or shocked. There is indeed a certain wise calm about someone who is rarely bothered by anyone. In some situations I asked permission to ask certain questions, to which he calmly said "I'll answer anything."
During this conversation, I learned that 1/3 cancers nationally are treated in relation to his speciality. He has around 150 people working with him and who, in some way, expect a strongly efficient coordination.
From the oesophagus to the stomach, by way of the pancreas, or the liver, or observing the intestine, with around just 7 metres to observe. The numbers are impressive: around 50,000 people a year in total come through the Technical Unit and the external Clinic. The Department admits 1,500 patients a year, corresponding to around 10,000 days of internment. The burden of assistance is very high.
Through talking with the Professor, I learned that he carries an Eastern charm from his time in Japan visiting his son João. Rui Tato Marinho thinks that we live to bring happiness to others because only this will make us happier and only this will make society better. He experiences the hard times of his patients: this is evidenced by the emotive descriptions of the dozens of patients that wanted to talk to the esteemed Doctor from the book "Hepatitis C, The Future Started Here." They don't forget how he received them, treated them and accompanied them, even when everything was apparently solved. He still does so, for never taking those life stories home. Practising to manage emotions as the pilot of other people's lives.
Out of 1,000 people, 999 leave Hepatitis C treatment cured; one drug is enough to eliminate the disease without any side effects. This has happened in little over 20 years and Rui Tato Marinho was a part of the entire process.
Medicine will always try to be the miracle that does more and more by saving people with diseases that arise throughout each century. People desperately want to last throughout this time that they think belongs to them forever.
But in this time where we play with immortality, we are meeting people like Rui Tato Marinho, who believes we deserve death more than not being able to look through someone, nor give them another chance.
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Joana Sousa
Editorial Team
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