Newsletter: Professor, how do you view the evolution of paediatrics over the last 40 years? 
Professor Paulo Ramalho: I believe that it must be analysed alongside the evolution of society itself, and the attitude it has had towards children. Up to the 19th century, and large part of the 20th century, children were perceived as small adults. Slowly, their particular characteristics started to become known.

The advancement of this knowledge also changed the actual practice of paediatrics, which impacted on attitudes, clinical approach, facilities, equipment etc.

In what concerns hospital paediatrics, I would say that we are still away from having balanced concepts regarding the distribution of hospitalisation zones (the classical beds…) and of support areas, complementary services, outpatient services, etc., which should correspond to about 60 to 70% of the total available space, and obviously this is not what we have at our hospital. Actually, one may say that nowadays we are becoming less interested in beds, given that the trend is for the number of beds to be reduced in favour of outpatient services. This does not mean we do not consider the need (and the right) of children to be in an non-“aggressive” environment, and which simultaneously enables them to maintain the link with their families throughout their stay in hospital. Nowadays, children can no longer be considered in isolation, but as part of a much wider structure – their families. Accordingly, we need areas that have been specifically conceived for children and their relatives. Given that buildings were not designed with that in mind, this has been a rising problem, particularly after paediatric age was extended to 18 years of age. On the other hand, the actual practice of hospital paediatrics has undergone a radical change over the past few years. It is worth remembering that, not so long ago, paediatric services allowed one or two hour visits, and that children were left on their own again. We take pride in the fact that we were one of the first services to have parents staying with their children all day long, which initially was met with great resistance. Professor Maria de Lurdes Levy was the first to defend this practice, which later became a matter of principle for Professor Gomes-Pedro.

On this matter, I recall an episode when I had to go to an infectology unit in Lisbon and which, as a young intern, shocked me profoundly: Before “visiting time”, a group of people waited in the hall. The sound of crying came out of the unit, and someone kept saying “it is my child…it is my child…” At midday, a doctor arrived, picked up a paper, and started to read out loud:
– Number 43?
– My child – someone shouts among the group of parents.
– He is better! Number 44?
– My child, another voice says.
– He is worse …
This type of situation, which we now abhor, was quite common in our country about 30 or 40 years ago.

Newsletter: do you think that period was a turning point in paediatrics?

Professor Paulo Ramalho: one cannot talk of a single turning point in the “course” of paediatrics. However, it was indeed after the 1950s and 1960s that a concept of children more focused on their completeness was developed, which somehow introduced some radicalism in the culture of those days. Subsequently, adolescents came to be perceived as a distinctive entity with specific characteristics, leading to the development of completely different attitudes. In fact, it was in this light that our Adolescent Health Unit was set up over ten years ago.
The Paediatrics University Clinic is located in a building that is over fifty years old, for which reason we have attempted to go along with that evolution by improving areas that, as much as possible, fit the new concepts. As such, we took over the HSM crèche after it was deactivated, and turned it into the Paediatrics Day Clinic. A garden, a pedagogical vegetable garden, and an area for story reading and entertainment by clowns were also created. This added to the educational work carried out by teachers and volunteers in the two waiting rooms. In the hospital infirmaries, in the Technological Unit, at Day Hospitals, we tried to set up areas as little “hospitalized” as possible, encouraging children to bring their toys, clothes, etc., to allow them to maintain the indispensable connection with their affective world.

Changes in paediatrics were not limited to physical and relational aspects. Practice also underwent changes, with the introduction of specific diagnosis and therapeutic approaches. One may say that until the first quarter of the 20th century, what we had was an extension of the pathology of adults, which left no room for metabolic or genetic diseases, or for newly born or developmental pathologies, given that everything was “extrapolation”.

At this time, it started to be recognized that a whole group of pathologies had to be approached in a specific way. It was a very European phenomenon, and the significant work of English, French, and German paediatricians later spread to the rest of the world. In Portugal, it was also around that time that a series of personalities began to be involved in paediatrics. Around 1911, as part of the re-foundation of the university, the Paediatrics Chair was set up and given to Jaime Salazar de Sousa, the director of a children’s infirmary at D. Estefânia Hospital. This was perhaps the first of the several turning points I mentioned earlier. He was succeeded by Professor Castro Freire, still at Santa Marta Hospital, and this is when a true school of paediatricians really began, as, for all purposes, they were the first paediatricians in our country. Later on, this time at Santa Maria Hospital, Professor Carlos Salazar de Sousa (the son of J. Salazar de Sousa), modernised and energised the existing Paediatrics University Clinic. He was brilliant in scientific terms and put our paediatrics on the international map.
Another turning point was the 1970s and the 25 April Revolution, when a generation of doctors started to question the orientation traditionally given to paediatrics practice. This generation, which I am proud to be part of, proposed that paediatrics should be perceived as internal medicine, with its own specialties and diagnosis and therapeutic techniques, which was not a widely known concept. For example, I recall that when Prof. Pinto Correia (who was far from being a traditionalist…) invited me to work at his Unit and I replied I was joining paediatrics, he said: “What for? You will only find baby food and vaccines there!”

That working group also laid the foundations of what is nowadays paediatrics training….

Professor Paulo Ramalho: It was not as you say, given that training was always a constant preoccupation of all the generations of paediatricians who preceded us. Our objective was to advance a new philosophy with regard to hospital practice, and to set up structures that were suitable for that practice: Specialized Clinical Units, Paediatric Techniques Units, and Hubs for the management of large surfaces, a library that worked as a centre for knowledge dissemination, etc. As such, we widened the range of paediatric training, and this practice ended up attracting an increasing number of followers all over the country. This is the reason why we became a training centre attended by doctors from all hospitals, and a valuable pillar for the differentiated development of Portuguese paediatrics.

You have mentioned training and replicating models. However, at the level of postgraduate studies, there must be doctors with PhDs to ensure the model is continued. There are not many PhD holders in this field.

Professor Paulo Ramalho: That is correct. I would say that, to some extent, this is due to the fact that we have never been a true “university hospital”, and have accepted the fact that it is possible to work without teaching and carrying out research, or that it is possible to do all these activities when we have increasingly less availability. How can anyone believe that it is possible to do research when you are required to be on 24-hour call at the Emergency Room twice a week, and still give appointments, do techniques, do infirmary service? This is an complete mistake that is still being permitted, as if one could cook omelettes without eggs. As it is, either decision-makers realize the importance of research and of pursuing an academic career, and give doctors the conditions to do it, or these two areas will always be waived by doctors.

Since you mentioned it, Professor, over the past 15 years, Paediatrics is the Faculty’s speciality with fewer doctors with a PhD.

Professor Paulo Ramalho: This is natural, in the light of what I have just said.

And, at this particular moment, paediatrics has the smallest number of Doctoral students.

Professor Paulo Ramalho: Currently we have only three. I will not deny it, but I do insist that the problem lies in the conditions that younger doctors have to face when they decide to carry out a doctoral project. The Doctoral Programme was fundamental to give interns a coherent perspective of this field, but I still believe that the basic issue lies in the organization of work, given that, under current circumstances, professionals must not be released from activities that are core to the Services in order to do research on a regular basis. A good example of this is when we compare the average age for PhD completion in clinical subjects and in pre-clinical subjects….

An understanding between the faculty, the Hospital, and political decision-makers is ever more necessary, to allow this situation to change rapidly, even because it has repercussions, namely in the quality of undergraduate teaching.

Actually, this is an area I believe also deserves profound reflexion. Besides the irrational rise in student numbers and the reduced availability of lecturers, teaching hours should meet the global objectives of medical education. See, for instance, the case of Paediatrics II, when students start to come into contact with paediatric pathology and, accordingly, should be predominantly practical. However, currently it only allocates 25% of time for direct contact with patients. It makes no sense whatsoever!

Professor, do you think the fewer PhD holders in this field and the quality of education that is being offered nowadays will make paediatrics more vulnerable?

Professor Paulo Ramalho: I have absolutely no doubt.

Has there been a regression?

Professor Paulo Ramalho: Each period corresponds to a particular reality with its specific characteristics. At this moment when the Doctoral Programme is being launched, changes in this area are to be expected, although I do not believe that the core of the current situation will undergo substantial changes. Let us go back to the case of Paediatrics II, limited, as it is, to twelve weeks of taught classes and twelve practical classes. No Integrated Master Degree will sort out this type of problem. I do believe that a major reflection on medical education is of utmost need.

In a few years time, we will have a totally different medical education, with less practice and a lot of theory.

Professor Paulo Ramalho: That model has, to date, been deemed inappropriate, and it would be like going back to medieval universities!

The Bologna Process is all over Europe.

Professor Paulo Ramalho: I have many doubts as to the real motives that made us adopt the Bologna Process, at least with regard to medical education. The least one can say is that the transformation was not sufficiently discussed. If I remember correctly, Bologna came about because Europe started to worry about American Universities (it would be good if it started to worry about Chinese and Indian universities too…). However, American universities stand out precisely because they have a huge practical and research component, something that continues to lack at Portuguese schools. All one has to do is to see what is going on with Master Degree dissertations, which are becoming review works with a residual research component. I do not think that was the purpose of Bologna.

Are you saying that the currently defended model of the doctor-scientist is impossible?

Professor Paulo Ramalho: I do not wish to sound so pessimistic. What I do believe is that, once more, we are missing an opportunity to improve the training of future doctors, and contributing to the development of the laxity that characterizes us.

Which are the vulnerabilities or shortages of the Unit?

Professor Paulo Ramalho: From what I have said here, the vulnerabilities that stand out the most in the Paediatrics University Clinic/Child and Family Department are related to the desirable compatibility between quality education and the needs of a hospital with undeniable structural limitations and major assistance responsibilities.

In this context, maintaining a culture of complementarity between the Faculty and the Hospital has been crucial. However, in order to continue, it must be coherent at all levels. Accordingly, it would be vital that all those wishing to work here knew beforehand that they could be assigned to carry out pedagogical or assistance duties according to the needs, opportunities, individual projects, etc. Nowadays, that unfortunately does not happen in clinical areas, where contracts are made taking into account exclusively the interests of hospitals. In the same fashion, the two institutions must unequivocally and quickly adopt an aggressive strategy to attract new professionals on a permanent basis, to be able to maintain the quality of the services that are provided and avoid, with plenty of time, the risks of an inter-generation gap.
Despite these constraints, it has been possible to develop this complementarity, as the use of common areas and human resources, and the electronic connection of our Library to the Library of the Faculty attest. In this light, it was possible to reorganize and bring together in one page of the Faculty’s portal all the information regarding paediatric training at HSM/FML. This fact allowed it to be disseminated among District Hospitals, Health Centres, and all the professionals associated to the health of children and adolescents.

Another objective is to set up a Centre for Paediatric Training encompassing the two institutional sides. With some alterations, the area formerly taken by FML’s Laboratory on the 7th floor will be dedicated to that training centre, which will enable us to seriously consider health centres, district hospitals, and Portuguese Speaking African Countries. This way, we will be in a position to implement the agreement made a few years ago between the Faculty of Medicine of Lisbon and the Agostinho Neto Faculty.

The dynamics that my predecessors conferred to the Unit must be maintained. I have many projects. What I lack is time…