AUTHORS: Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov
In this series the Medspire team interviews doctors about their career, their specialty, the choices they have made and their advice for doctors and medical students.
Here the subject is Professor Beverley Hunt, who is a professor of haematology at Guy's Hospital in London. Professor Hunt is an international expert in both thrombosis and haemostasis. Her key achievements include developing national guidelines for the prevention of venous thromboembolism, and setting up her own award-winning charity, Thrombosis UK.
A podcast of this interview is available here:
How did you get to where you are today?
I never knew when I started out what I would do, or where I would end up. I have never been one of those people who came out of medical school and thought that they were going to be doing something specific. I went to Liverpool Medical School. I loved it. I did a lot of things outside of medical school - I sang in a band and had the greatest fun ever.
I did a lot of acting as well with the Medical Students Society. It was fun, but very hard work. After medical school, I stayed a few years in Liverpool. Then I came home, which is really London and the South East. I wanted to see a lot of general medicine, so I rotated around numerous specialities, but I kept thinking about haematology.
When I was in Liverpool, the professor of haematology there encouraged me to do haematology. At that time, you could do locums before you were qualified, so I used to do a lot of locums in haematology and also in tropical medicine - which is interesting, because that's back where I am now. I did lots of general medicine.
I always wanted to do general medicine, but it is closed off. Cardiology has taken cardiology out of it, and gastroenterology has taken gastroenterology out of it. In the end I thought: ‘Hey, haematology’. I get to make the diagnosis. I run the lab - you are very dependent in any branch of medicine on the lab - and I also see patients.
I have patient groups, some who I've known for 30 years. I also get acute illnesses coming through - DVT, pulmonary emboli - and we have exciting things, like a pulmonary embolism, and a thrombolysis team. We see very sick patients. I am doing what I set out to do, which is to still be very much part of acute chronic medicine and also the laboratory.
Then there's research. I started researching a few things very early on. I was always encouraged to do that, and I loved the process. If you ask a question and you can get an answer by investigating it with some simple process - it’s much more complicated these days - it's such a pleasure to increase knowledge. I'm not doing huge things - I'm just chipping away in the areas that I understand.
What are the biggest changes you have witnessed?
It's totally different these days. When I started out, if you look at the big textbooks, which weigh about a kilogram, there would be half a page on managing thrombosis. What do I do during my working day?
Well, it's 95% managing thrombosis and acquired bleeding disorders, which were actually never mentioned in the original book. Out of nowhere, we have this explosion of knowledge about thrombosis and I'm very much a part of it. I'm not actually a general haematologist anymore, I really only do thrombosis and bleeding.
How did you first become involved in research?
When I started out, the consultant I was working for would say: 'Oh, this case report needs writing up’, and I'd write it up. Then I worked for a neurologist who had a research question about sixth nerve palsy, so we did a bit of work on that.
I went on to do a respiratory job and we realised there was no normal range for looking at some of the tests being used, so we did that, and published that. By the time I got to be a registrar, I already had a portfolio of little, tiny projects that I'd done.
When I went into haematology, I realised I needed, and wanted to do, an MD or a PhD. I was offered a few, and finally plumped for looking at haematological problems after heart and heart-lung transplantation. I went to work with Professor Sir Magdi Yacoub at Harefield in the very early days of heart and lung transplantation. We looked at all sorts of things together.
Then Magdi always used to call me into theatre when patients were bleeding. So I started to get involved in trials of drugs to try and reduce bleeding in theatre, which got me into managing acquired bleeding. Then I realised that nobody had really done any research there, so I started off down that road. I suppose I have just taken most of the opportunities that have come my way.
Now I am pretty well known, and so I'm invited to join various groups and collaborate as, I guess, the wise person in that area.
I'm still doing a lot of research. At Guy's and St Thomas' we have collected probably the biggest number of patients with antiphospholipid syndrome in the world. We have got quite a programme of research going there. In 2000, I set-up the charity Thrombosis UK because we realised there was nowhere to go to get funding for research on venous thromboembolism.
I then became aware that there's a real problem in the UK with thromboprophylaxis in hospitals. It was very poorly delivered. So we campaigned to mandate proper thromboprophylaxis in all the hospitals.
That meant that by 2010, NHS England said: 'Okay, we'll mandate VT risk assessment. We'll ask NICE to write the guidelines’. I was on the NICE group. That has had an amazing effect on reducing mortality due to venous thromboembolism in the UK. It's a little-known fact - especially among medical students - that with 60 per cent of all acute hospital admission, venous thromboembolism either occurs in hospital or for up to 90 days' post discharge.
If everybody gets thromboprophylaxis we're reducing the rate by about 50-to-60 per cent. That has reduced mortality in the UK. Now, at a global level, I'm working with the World Health Organization to take out what we've done with NHS England across the globe. It's been slowed down by COVID, but we are making progress.
COVID is really the most prothrombotic state I have ever seen. We did some early work looking at our very sick patients from critical care. We showed how sticky their blood was, looked at rates of venous thromboembolism, and recognised that when we looked at CT pulmonary angiograms, there were two problems.
We've got the pulmonary emboli, but we've also got tiny microvascular in-situ thrombosis, which we call ‘immunothrombosis’, because patients have got so much inflammation in their lungs with acute respiratory distress syndrome, they're getting little, tiny thrombosis.
We have just compared the changes that we’ve seen on CTPA with COVID with other pneumonias due to viral problems over the last ten years, and shown that actually, COVID really does cause more thrombosis than all the others.
We produced some draft guidelines really early on, before any of the big groups, to say: 'We think this is how you need to manage these patients with thromboprophylaxis and the dosing’. That has been incorporated into all the international guidance.
I now work with NICE on the living COVID guidance, and also, importantly, the WHO COVID-19 living guidance, as the person who is the expert in thrombosis and prevention of thrombosis.
What are the challenges of studying thrombosis?
It's been a rather odd journey, because back in March 2020, we knew from papers that had come out of Wuhan that there was a coagulopathy in patients with COVID in hospital. Let's remember that COVID causes COVID pneumonia in a small minority of people.
Most people have mild COVID, by which I mean they have a bit of fever, or nothing, or they lose sense of taste and smell, but they don't go to hospital. It's this minority that get COVID pneumonia - they get hypoxic, they have to come in and receive oxygen, and maybe assisted ventilation. If you've got mild COVID, you don't get sticky blood.
We've got the COVID pneumonia patients in hospital, and we were expecting them from the Chinese literature to have disseminated intravascular coagulation. The Chinese literature said: 'They've got really low platelets, they've got very prolonged clotting times and they've got disseminated intravascular coagulation (DIC)’.
What was so surprising was that when we started, and we had 66 patients on ventilators at my hospital last March in the first wave, they all had incredibly sticky blood, and they didn't have DIC at all. They had very high levels of fibrinogen, very high levels of D-dimer, which was much more in keeping with an acute phase response that you would see in people who had a lot of inflammation in their lungs.
It looks like the lungs are producing cytokines, which are telling the liver to produce more coagulation factors. It's really that simple, but the levels are just enormous. I've not seen fibrinogen levels that we've seen in COVID ever before - and I've seen a lot - so that was very surprising.
We thought: ‘Hang on, this is not right’. So then we published our data and other people in Europe published the same, saying: 'We've got this very sticky blood’. Then everyone in critical care was saying: 'We're seeing so many clots when we put people on renal replacement therapy. They're clogging off their circuits. They're getting pulmonary emboli.
They're getting DVT’. There was a mass move from those in critical care to say: 'Look, we're giving standard thromboprophylaxis, but it's not enough, let's give some more’.
Many units independently increased the amount of heparin that they were giving their patients without any evidence, and it's only in the last few months that we've had the results from the platform trials and randomised control trials to tell us how we should manage these patients. I'm part of these groups. Last March the Chief Medical Officer stopped all research apart from COVID research, so all my trials had to stop.
We were allowed to do COVID research, but we were only allowed to do proper, really well-designed, randomised controlled trials, and for most of the patients we were using two, what we call ‘platform trials’. One was RECOVERY, which looked at various aspects of care in the patients on the ward.
We're talking about patients who are on supplementary oxygen. And then we've got REMAP-CAP, which is a purpose-designed platform trial that happened to be around and had been developed by the WHO just before COVID. That was used for the critically ill patients - the ventilated patients, or those on continuous positive airway pressure.
Early on in the trials, they weren't interested. They didn't get the fact that there were high rates of thrombosis. It was only last summer when they started to wake up, and REMAP-CAP set-up a trial comparing standard thromboprophylaxis with full dose therapeutic anticoagulation to try and prevent the clots.
The results of those trials were published as an interim result in February. When you run a platform trial, you've got a data monitoring committee that keeps looking at results to see if there's a message, and they stopped the trial of the anticoagulation in the critically ill patients in December because they said: 'Hey, we've got a result’. Those results came out. They're still not published yet in any journal, and they haven't been peer-reviewed.
This is a unique phenomenon of the pandemic. RECOVERY did the same with the dexamethasone results. They said: 'Hey, dexamethasone is really improving mortality’, and they announced it through the press, through Twitter. That has happened in the same way with the anticoagulation. Hopefully, in the next few weeks, it'll come out in a really major journal after peer review.
They presented their results in PowerPoint format, which went out. This is what we did with REMAP-CAP - they were sent out to lots of individuals across the world and put on Twitter and Facebook and through a press release first, before even a preprint was written. A preprint is: ‘Oh, I've written the article for the journal, but I'm going to put it on a preprint site so that people can have a look at it, because that's giving more details’.
Whereas what you do with interim analysis, you get the main message out, but you haven't done the secondary questioning that you need to do on your data before you can publish it.
Are preprints a good thing?
A lot of clinicians don't always trust the interim analysis data, especially as the results from the REMAP-CAP anticoagulation trial were not what people expected. The results said, if you've got patients who are on the ward with supplementary oxygen, they should get full-dose anticoagulation to prevent clots, whereas those who are in critical care, they don't do well, and you don't improve outcome.
They're more likely to die, they're more likely to bleed, and they need to just have standard thromboprophylaxis. A lot of people struggled with that, so they haven't followed the interim results, and are saying: 'I'm waiting until the paper is published’. Thankfully, NICE has looked at the interim results, spoken to the trial people, and they have taken the results on board.
How did you develop the national guidelines for preventing venous thromboembolism in hospitalised patients and get them implemented throughout England?
We had some connections with the House of Commons. John Smith MP had a patient who died of travellers' thrombosis after a long-haul flight, and he wanted to talk to us and advertise the problems with long-haul flights.
These flights are associated with clots, but they're a very rare phenomenon - usually people who get travellers' thrombosis have underlying risk factors, and they may be very immobile on the flight. We pointed out to him that actually, the biggest problem within hospitals was the failure to give thromboprophylaxis. There just wasn't a system in place to do it. We took it further.
I was working at the time with Ajay Kakkar - now Lord Ajay Kakkar. We went to see Richard Taylor, the chair of the Health Select Committee at that time, and an independent MP, who had got into parliament because they were trying to close his local hospital. He kept that hospital open.
We told him all about the issue - that you could go to one hospital, have a hip replacement, get no thromboprophylaxis and have a high rate of having problems, while in another hospital, they'd be following someone's guidance. He said: 'This is outrageous. This is entirely preventable’. There was an emergency Health Select Committee, within a few months, which spent a day talking about venous thromboembolism in hospitalised patients.
Many of us gave evidence as to what the size of the problem was and how we needed to tackle it. One of my suggestions was that every hospital should have a thromboprophylaxis committee to monitor and police the situation. That happened.
They then have to produce a report within six months, and that report came out. The press didn't take it very well - they castigated doctors for not following proper guidance. But the results of that report was that the Department of Health at the time took up every word that was spoken, except the business about mandation.
All hospitals had to set-up a thromboprophylaxis committee, and NICE were commissioned to produce guidance, which they did over the next three years, so things were in progress. But there was still nobody saying: 'This has to happen to every single adult that comes into hospital’, because having a blood clot that's not been prevented is the number one preventable cause of death from hospital admission.
Never mind hospital-acquired infection and all of the other things that had a lower death rate. We had to continue to campaign, so the charity was growing at that time, and we were able to organise teaching sessions. We worked with healthcare professionals, and a parliamentary committee. By this time, an all-party parliamentary group on thrombosis was set-up, and we campaigned and campaigned.
Finally, in 2010, Sir Bruce Keogh, who was the Chief Medical Officer at the time, agreed we needed to mandate it. They set-up the system whereby they asked for 95% of hospital admissions to receive VT risk assessment and then receive appropriate thromboprophylaxis.
The driver for this - it always comes down to money - is that if the hospital did not achieve this, then they would pay a financial forfeit, which would be about 1% of the hospital income. That's huge. So suddenly the hospitals were interested, and each of them set-up their committee, gave them money and got the system going locally. Since that time, it's been part of the NHS contract that you have to deliver on VT prevention.
Over what time period did this happen?
We started campaigning in 2002-2003 and we were talking to John Smith during 2004-2005. In 2010 VT prevention was mandated. There was an awful lot of talking over an awful lot of time. Now, we have the same issue. We want to take it out globally, and have been talking to the WHO for three or four years. We’re slowly getting there. It takes a long time to make a change.
What research questions do you hope to answer next?
I always want to know more about COVID and clots, and coagulopathy, so I will be continuing my work there. I think I am a great educator on this. Last night I did my 71st webinar on COVID and clots, and I haven't done the same talk once, because every week there's more to learn about COVID and clots.
I want to continue working with the WHO on the living COVID guidelines. What we internationally have neglected, and what we must concentrate on, is the post-COVID condition - ‘long COVID’ as we call it. There are issues here, and I have got involved.
I'm really interested in viruses and haemostasis - before COVID came along I had been doing some work on Ebola and I want to continue that. I have got a research fellow coming over from Sierra Leone, and we're going to show him how to set-up complicated haemostatic assays, so we can try and work out why people bleed with the viral haemorrhagic fevers. We’ll probably get some samples from Lassa fever as well, because that's been reasonably common in Sierra Leone.
Another area is the viral haemorrhagic fevers - we're not clear why people bleed. Then, with antiphospholipid syndrome we have so many questions to answer. We really don't understand why people get thrombosis and why they have pregnancy loss, so there's that to be done, and clinical trials.
We are in a unique position with APS in that we have so many patients that we can actually run reasonable clinical trials in just one centre, whereas most people only have two or three cases. Then there are the acquired bleeding disorders - I constantly do work on tranexamic acid and other agents to try and reduce bleeding.
What advice would you give to anyone interested in pursuing a career in clinical academia?
I am far from a typical researcher, and the average pathway these days is much more conventional - people get mentored, and they concentrate on one area. I never really got any mentoring and I just dealt with what came along and went in with wild enthusiasm.
You need to decide: ‘I'm going to work in this area, find the right people who work there, get a grant and a lectureship, and push on’. I'm probably a dying breed because I was allowed to do whatever I wanted for so many years. People said to me: 'You're a bit of a scattergun, aren't you?' It's like: 'Yes, but these answers are needed and no one else is working in the area’. I was working in areas where no one else was at all interested, but they have all stood me well over time.
I have a lot of fun with research because it is always fun analysing data. The other problem with modern research life, especially clinical trials, is the amount of bureaucracy that is there to monitor what you're doing and to make sure that there are no errors. You spend most of your time dealing with that, rather than actually doing the research.
The research environment needs improving, and I'm hoping that maybe after Brexit has died down in the UK, we can try and improve our research environment so it isn't so bureaucratic.
How can the WHO be improved?
The World Health Organization has to exist, doesn't it? We need it. Working with them on the living COVID guidance has been phenomenal. They have an amazing team of statisticians and there's a big panel - about 50 of us clinicians from across the world helping them write the guidance - so it works brilliantly.
Not all areas of the WHO are so speedy and accountable, and some of them are very process-driven, and not really aware of what's happening on the frontline. It's a constant struggle to try and talk to the right person to get a change delivered. It's the same with the government. Look at me - we've spent years trying to get the Department of Health to mandate thromboprophylaxis.
My message to everyone is if you really want to make a change, just keep banging on the door and never give up. Eventually, change will happen, but it will often take years and you have to accept that that is how life is.
Tell us about your time as a presenter at the BBC?
I was an actress at medical school, and did a lot of acting. The BBC got to hear about me and I got offered some presenting jobs. I actually said no to them to start with. Later on, I got offered some BBC Open University work, to look at decision analysis and I decided it would be really fun to do.
After that, I was offered some more presenting jobs with the BBC but I didn't really enjoy it and so I stopped doing it. What did I get out of it? Well, you get an intimate understanding of how they make films and what they want.
I've got very good at delivering a soundbite - so in very simple terms just saying, 'This is the problem’, in a few seconds. In the last few weeks, I've been doing news programmes, talking about the vaccine and thrombosis, and I can deliver very clearly what's happening with just a few words.
These days, the science presenters on news programmes actually want to talk about it. First, you tell them about the problem so they understand it, and they just want this little sign back from you, slightly emotional, so that they can help deliver the messaging. I have written a play and that was also helpful.
The whole process of writing when you have to make every word count is the same as when you write a scientific article. Every word has to be the right word and count for something. That is what I try to do when I might be asked to comment on something on radio or television. Some people say too much, but the less words you can use, the better.
What was the play about?
I wrote it with somebody who was already a playwright - she's really good with words and she wanted a medical story. We wrote a play called Death and Taxes, and it was about a woman who was dying - a wonderful woman - and a doctor who was very damaged, who was looking after her, and how she helped him get through life.
There is this thing that many people go into medicine because they're wounded healers and they are wanting to help others because they need help themselves, so the play really addressed that. It was very humorous. Mary, who I wrote it with, is a bit of a comedic actress, so it was black humour. It was fun to write.
It won a prize in the European play writing competition, and we put on a rehearsed reading with Emma Thompson's husband, Greg Wise, and Janie Dee, who's a West End actress. It was fun. I’ve no time to do any more writing though. But that's what I'm going to do if I ever stop working. I'm going to write.
What are your proudest achievements?
My children. I have two wonderful children, and as a woman, that is so important. At the end of the day, they're not going to write on my gravestone anything about work, it'll be about being a family person. That side of life is very precious.
Do you have a good work-life balance?
No, none at all. I work all the time. I have been blessed with enormous energy and I never rest. Maybe I’ll have a glass of wine and sit down for a little while, but most of the time I am doing something.
What were the key moments that have defined you?
I can't answer that! I don't know, because we're all different, aren't we? We are all like multifaceted diamonds - you will see a few of the facets, and someone else will see another few facets. I don't know what defines me or what other people think defines me.
I look back, and I think as a medical student, the most profound message I received was sitting in clinic with a physician who was saying that the most important thing that you can do for your patient - because we have so little to offer, and remember, there is a lot we can offer now - is kindness.
To let them leave a consultation with you, feeling better about themselves, because nobody else is doing that for them. That was profound, because I have always tried to be very approachable and when you can't offer things to patients - and that happens less frequently these days - you can offer kindness and make them feel better about the situation that they might be in.
What habits have you developed?
I read a lot. Before Twitter I scanned The New England Journal, Lancet, BMJ, Blood, and a few other journals every week for my area. Now, Twitter has really helped in focusing down on the key articles, so I follow a fair number of people on Twitter. People follow me and let me know what's happening, and it really is the place to go if you want to keep up to date.
What's your favourite book - one non-medical and one medicine related?
It's Pride and Prejudice by Jane Austin. I never tire of reading it, I must read it at least once a year if I get a chance. It's so witty and she understands people. It's a real pleasure to read. I don't have a medical book - I don't read them. Nobody reads medical books anymore, do they? My favourite journal is the New England Journal of Medicine.
Medspire podcasts are produced by Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov, both full-time junior doctors. They aim to inspire the next generation of doctors and scientists by exploring the career journeys of leading clinicians and researchers.