News nr. 37 | October 2013
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Interview with Professor Gonçalves Ferreira, Director of the Institute of Anatomy
Interview with Professor Gonçalves Ferreira, Director of the Institute of Anatomy







What are the origins of this institute, its creation, founders, and key moments in its history?



Anatomy is a very old subject. The first Medical School in Portugal dates back to 1290 and was founded in Lisbon. At the time, it had three core subjects, Anatomy being one of them. Indeed, Anatomy is one of medicine’s oldest subjects, not just here but all over the world. However, a service or faculty department with its own structure called Institute of Anatomy only emerged at the beginning of the last century. This Institute was founded in 1911, shortly after the establishment of the Republic. Professor Henrique Vilhena was the promoter and first director of this Institute, between 1911 and 1948. This does not mean there were no anatomy subjects with a lot of weight within the Faculty of Medicine before that date. This is attested by the fact that the Anatomical Amphitheatre of our Faculty was named after José António Serrano, precisely because this anatomy professor of the late nineteenth century was renowned worldwide; in those days he published a treatise on human osteology that is still occasionally referred to.

The Institute of Anatomy started in 1911 in Campo Santana, where the old Faculty of Medicine stood. It was only when the Teaching Hospital of Lisbon, later named Santa Maria Hospital, was created that it moved to the location where it is today, The Institute has had several directors over the years. The successor of Professor Henrique Vilhena as director was Professor Vítor Fontes, responsible for the major move of the Institute from the old facilities to the present location. He was director between 1948 and 1963. When the Teaching Hospital was built in the 1950s, the facilities of the Faculty of Medicine were moved to this place. Professor Armando dos Santos Ferreira was also another director who stayed in post for a long time, between 1964 and 1991.

Each director was responsible for different and equally important stages in the development of the Institute. Professor Henrique Vilhena was the founder and he succeeded in turning a single subject into an entire department. In the period of Henrique Vilhena and Vítor Fontes, Anatomy was split into two – Descriptive Anatomy and Topographic Anatomy – and this Institute hosted students with different training backgrounds: medicine, pharmacy and fine arts. The well-known sculptor Soares Branco worked here and produced several anatomical art pieces that are still kept at this Institute. At the time, the Institute was home to a variety of occupational categories in addition to lecturers, such as the profession of drawer-photographer. I still remember Henrique Restani, the last drawer-photographer of the Institute. It was only after the 1974 April Revolution that the restructuring of the Institute and of the Faculty took place.

Long before that, the first phase of the life of the Institute of Anatomy corresponded to the first half of the twentieth century, when Anatomy continued to be one of the basic components of medical education. Then, due to the proliferation of new basic medical, morphological and functional fields, among others, and to the development of cell morphology and, later, molecular medicine, Natural Anatomy experienced gradual decline. Of course, anatomy had to adapt and make room for the inclusion of all these increasingly more important subjects. However, it never ceased to play a key role, although its importance diminished, particularly with regard to the descriptive detail of human body structures. From the 1950s and 1960s onwards until the 1970s/80s of the last century, Anatomy clearly went through a period of progressive decline, leading to the fragmentation of anatomy societies into an array of scientific societies, each with one specific focus.
In the 1970s/80s there was a revival of anatomy throughout the world (including Portugal), particularly in its clinical and applied uses to surgery and imaging. This happened for several reasons: one the one hand, clinicians, and surgeons and radiologists in particular, necessarily had to know more about anatomy than they knew before. On the other hand, it was due to the fact that old anatomy books were based on the description of a limited number of isolated cases. Finally, because anatomy had ceased to require a kind of encyclopaedic knowledge and became consistent with more integrated medical education. A new anatomy – clinical anatomy – appeared, which is anatomy applied essentially to clinical practice and imaging. The advent of the major in vivo imaging resources such as CT and MRI in the 1970s and 1980s revived the so-called anatomical imaging, which, in reality, is anatomy in vivo; it then became absolutely necessary for curricula in the various faculties of medicine to have this type of approach, bringing together the teaching of anatomy and imaging. This is the case of the current syllabus of the medical degree offered by our faculty, where normal anatomical imaging is taught to medical students alongside anatomy. To that effect, we work closely with Professor Jorge Campos, who is responsible for imaging at FMUL and for its connection to anatomy. This revival of a more clinically focused anatomy had great visibility around the world with the emergence of Associations of Clinical Anatomy. These associations flourished in the US and in Europe, particularly associations of a supranational type. For instance, in Europe there are two that are very important: the European Association of Clinical Anatomy (EACA) and the British Association of Clinical Anatomists (BACA). From an early stage of my career, which has always been two-fold – academic in Anatomy and clinical in Neurosurgery – I have been interested about this interdisciplinary relationship and I have always believed that the future lies in the association between related scientific and technical areas. This link is increasingly growing because a lot of people are doing research in anatomy focusing on clinical practice. This led to our growing participation in those international organizations such as EACA. This is reflected in the fact that our Faculty hosted the European Congress of Clinical Anatomy in June this year, jointly organized with the British Association, and which attracted hundreds of participants from around the world. At the congress I was elected chairman of EACA for the next two years.





 


Currently, what are the Institute’s main activities in terms of teaching, research and clinical practice?


Teaching and research: teaching has long been ministered by lecturers with clinical training, as in the time of my predecessors. All lecturers and assistants who work here are people who also carry out clinical activities which, from an educational point of view, are very important and positive, since they have a natural capacity and tendency to deliver more pragmatic clinically oriented teaching. However, there is a drawback: people who have a clinical activity, most of whom working here on a full-time basis, have less time to carry out research than people working on other basic subjects. Generally speaking, they are not research professionals, nor could they ever be. Indeed, the research undertaken at a basic department of applied science, as in the case of anatomy, essentially focused on clinical and imaging anatomy, is always research that has to be conducted by part-time physicians. Researchers can only conduct research and seek to address unsolved scientific issues in areas that they know as a whole. One can only do research in an area that one totally masters. For instance, Professor Ivo Furtado, who works in a specific clinical area – a stomatology – has been carrying out anatomical research in that field. It is this type of clinically focused research that has been practiced in recent years, including basic and laboratorial aspects. The nervous system has been the main focus of applied research. In this context, I am supervising three specific projects: one will culminate in a PhD thesis by the end of the year; the other will result in a master dissertation; and the third is being initiated now. Another research area currently being developed by Professor Ivo Furtado is dental anatomy.

However, much of this Institute’s activity is educational, as it teaches the anatomy studied in three modules of the core subject group of the medical degree and the bachelor degrees in health sciences and biomedical engineering. This means a lot of classes in both semesters.
There is another teaching component that has been inactive until now, which is specialized anatomy. However, thanks to the new Anatomical Theatre, it will start again. These days, this type of anatomy is not for medical students, who require a kind of anatomy with less morphological details and more applicability to the profession and clinical practice. Anatomical detail is crucial for postgraduate teaching of different medical specialties. For instance, Orthopaedics is very interested in the detailed study of bones and joints; clinical neurosciences (Neurology, Neuroimaging) are very interested in everything concerning the central nervous system. There is increasing number of postgraduate practical courses in applied anatomy worldwide: I give you another example: last week I was in Ghent, Belgium, for two days, giving theoretical and practical classes in the second edition of a European course in epilepsy surgery: my role was to present anatomy related to a set of surgical techniques. The practical classes were held at the anatomical theatre of the Faculty of Medicine of Ghent. We also have projects to implement at our new Anatomical Theatre; these are other kinds of courses, usually known worldwide as hands-on courses, of interest to several specialties.

 


The Anatomical Theatre was inaugurated on 12 June last. How does it feel to see it almost completed and what are your expectations about it?

The Institute of Anatomy, with its properly equipped Anatomical Theatre, is finally ready to be used in undergraduate and postgraduate practical education and research. It was great to accomplish this project, as it was a key venture for this Institute and the Faculty. For years, we were the only medical school in the country without cadaver dissection, which is essential for students to learn anatomy directly. For many years I remember visiting many foreign institutes of anatomy to see what they were like and borrow the best ideas to apply here. Seventeen years ago, I and Professor João Paço, still mere assistants, visited a New Anatomical Theatre in Barcelona, an example that was to be followed “shortly” in Lisbon. However, this “brevity” kept being postponed…until now. Meanwhile, there were some remodelling aspects that proved complicated to solve, namely the change in current European legislation, which became much more complex. For example, before we used to keep the bodies in formaldehyde, but now it is impossible due to formaldehyde’s toxicity; these days, it is not possible to have an Anatomical Theatre without a special air conditioning system, preferably with a laminar flow, as in operating theatres, or a system of special autopsy tables, among other specificities. Thus, a simple renovation job became a reconstruction, ranging from the structure of the walls to the acquisition of sophisticated equipment, everything costing ten times more. It was clearly more unattainable in logistical and financial terms, which were further aggravated by the national and international crisis. Fortunately the work was done and now we have a finished anatomical theatre. Some minor equipment is still lacking, expected to be purchased gradually in the coming years. Still, the main part is done and this will enable us – as soon as we have a reasonable number of donated bodies and organs - to provide better education and undertake enhanced research.

One of the most striking things in anatomy is the direct contact with the body, learning how to dissect and deal ethically with the corpses we have at our disposal to study and research. Unfortunately, it was not like this always because materials and equipment deteriorated and for years students had their practice restricted to the dissection of small isolated organs. It is extremely important to resume large-scale dissection. The former Rector of the University of Lisbon, Sampaio da Nóvoa, was very much aware of this need, which accelerated the process. The actual Faculty played a major role, in some aspects, quite a decisive one.

The corpses we receive to study and research come from a list of donors. Currently, Portuguese legislation is very favourable to the donation of organs and bodies, as long as people have not previously opposed to it by registering in the official list of non-donors: no body donation official declaration must be countered. Nevertheless, if the family strongly opposes the donation, we must not insist on it; the sensitivity of each person and family on this issue varies a lot and must be respected. We currently have a list of over 300 registered people who wish to donate their bodies to science.
Thanks to the support of the Rector’s Office and the Board of the Faculty, we also succeeded to build, as an attachment of the Anatomical Theatre, a plastination laboratory in two rooms in the floor below. Plasticised or plastinated anatomical organs are currently increasingly important teaching material worldwide due to the limited number of bodies available. One of our technicians went abroad to do a course to learn this technique. We succeeded in getting the basic equipment and the facilities to build this laboratory, which will start soon and be the first of its kind in Portugal.


Regarding the training of future physicians, what goals are set for their anatomical training?

It is intended that students become familiar with human anatomy in a functional sense and in moderate depth. As I said earlier, not detailed anatomy, but not just in general terms either. This is because anatomy has several roles in relation to medical students: the first major role is the contact with the human body and the first major purpose of education is to teach students to become familiar with the human body. Another purpose is to know anatomical and medical terminology: anatomy is the first major subject at the beginning of medical school when students learn medical terms and the names of several parts of the body, from the large things to the smallest. There are other occasions in medical education, especially in practical teaching, where there is contact with anatomical material. It is important that medical students learn to work with variability, since things are not the same in everyone. Accordingly, the anatomy they learn in books is based on average sizes, trends (statistics), in other words, on what is more common. There is another notion related to the concept of variability that is very important – the distinction between what is normal and what is pathological. One of the purposes of teaching anatomy is to encourage students to undertake research to address still unsolved scientific issues.

One of the first challenges of Applied Anatomy came in the 1960s/70s with the advent of the surgical microscope, an essential tool for many surgeries. When many anatomists, in the beginning of microsurgery, started to see how the details of most organs of human anatomy had been described, they realized that very little was known about them. That is, the majority of anatomical descriptions were macroscopic descriptions of a set of organs and systems, and nothing was known about the specific variations of certain structures. And the most common variant corresponds to what percentage of cases? 80%, 90%? This type of information is very important when a surgeon observes any area of the body through a microscope and is about to dissect a small, thin structure, and it is decisive because it prepares us for details and the variations we need to face. Today, anatomy has that new role, which is microsurgical anatomy, one of the fields in which there is renewed interest. When it is said that anatomy is a fixed, immutable science, indeed it is when it comes to the major topics, but not in terms of detail. Teaching medical students should not be just about generalities, but it cannot be as deep in morphological detail as it was fifty years ago; it needs to be more integrated with the function and clinical practice, which makes it necessary to look for detail in the different medical specialties. Nowadays, anatomy plays a more important role in the teaching of medical specialties, which counteracts the lesser weight it has in basic medical training.

The European Joint Congress of Clinical Anatomy took place on 26-29 June 2013 at FMUL. How significant is it for Portugal this important scientific event that brings together some of the world leading authorities in Anatomy?

I think that this congress was very important for several reasons: it gave colleagues from around the country the opportunity to attend, present their work, socialize, and update knowledge. It was also an opportunity to be with peers from around the world, some of whom renowned and a reference in this field. It was also a chance to affirm our Faculty internationally. These European Congresses of Clinical Anatomy are normally held at prestigious universities. The mere fact of being held here means two things: that our Faculty is considered to be prestigious and that the people responsible for the organization are credible in their respective area and specialty. The Faculty of Medicine and the Institute of Anatomy are held in high regard, to the extent they were asked to organize this event. There was a lot of pressure from me and the Faculty to inaugurate the new Anatomical Theatre a few days before the congress because, despite not having bodies yet, it was possible to bring in many guests and show them this new facility, which is a small (in European terms) but very good Anatomical Theatre that fits our needs perfectly.


What do you consider to be the contribution of this Institute of Anatomy within the Lisbon Academic Medical Centre?


It plays an absolutely vital role, which is the renovation and updating of medical education. It is very important for medical students to learn anatomy well and in a practical way. This means including anatomical dissection in their training. The role of anatomy is as important as before in the undergraduate programme, despite having been successively reformulated and being different in nature than it was fifty or one hundred years ago. It is equally increasingly important in postgraduate training. From next year we will have a growing number of initiatives, courses, and postgraduate training courses in various specialties in the new Anatomical Theatre. During this hands-on epilepsy course where I was last week the Board of the European Society of Functional Neurosurgery asked me to offer a European course on the anatomical bases of this surgery here at the Institute in two years’ time. This is a very interesting proposal because in many parts of Europe it cannot be accomplished. We are fortunate to have the experience, mine and of those who work with me, of large basic-clinical integration that cannot be found in many other places where anatomy departments are completed detached from clinical practice. We must encourage this integration both at undergraduate and postgraduate levels, which is an area with enormous potential.


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