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 Bijan Modarai who is a professor of vascular surgery and consultant vascular surgeon at Guy's Hospital in London. Professor Modarai is a British Heart Foundation senior clinical research fellow, and he co-manages the largest UK practice of complex endovascular repairs.
A podcast of this interview is available here:
How did you get to where you are today?
I have been, in one shape or form, at Guy's and St Thomas' since 1992. I first started there as a student, and graduated in 1998, having done an intercalated BSc. I then did my basic surgical training at Guy's and St Thomas', and after spending some time in Kent, became an academic clinical lecturer.
I finished my training at the end of 2011 as an academic trainee. In that interim period, before taking up the clinical lectureship, I did a PhD. I was appointed as a British Heart Foundation Intermediate Research Fellow and senior lecturer in vascular surgery to King's College London and Guy's and St Thomas' in 2012.
I embarked on a clinical academic career and became professor of vascular surgery in 2018. I'm working in that capacity now, and also, as a British Heart Foundation senior clinical research fellow.
What attracted you to vascular surgery?
I've always been interested in surgery. Even before I'd contemplated medical school, surgery was something that appealed. I was very conscious that one has to be aware of the reality of being a surgeon before choosing surgery. I was open to different options through medical school, but actually, at the end of it, and having undertaken my basic surgical training, it was obvious that vascular surgery was always my passion.
It's quite a technical speciality. It's quite holistic in that you have to look after the whole cardiovascular package that the patient comes with, ie, the medical side at times too. It's exciting. Half of the work that you do is emergency based.
After weighing up all the different factors, including lifestyle and how much time commitment would be involved, I decided to go for what I was passionate about, and I'm very thankful that I did.
What are the biggest changes you have witnessed?
The biggest change has to be the fact that the treatment of vascular disease has evolved over the past 20 years, and certainly accelerated over the past decades, to become minimally invasive. For example, not so long ago, the treatment of aortic disease involved only open surgery - a big laparotomy, thoracic abdominal laparotomies.
That's evolved now using stent grafting technology, where the aneurysms realigned essentially from the inside, from two one-centimetre incisions in the groin to access the femoral arteries. That's a big change. It’s much less of a hit to the patients compared with big open surgery.
We now have that tried and tested alternative. It's not suitable for every patient. There are some questions of the durability of the minimally invasive technique going out to ten, 20 years, but for a big cohort of patients, this minimally invasive technique is a big advance.
It applies to the aorta and to the peripheral vasculature as well. Instead of doing surgical bypasses for all patients, the majority of the peripheral arterial disease is now treated using angioplasty and stenting. That is far and away the biggest change in vascular surgery.
Where do you see vascular surgery heading in the next ten years?
I'd put it into three different categories - where we've still got some work to do is selecting the best way to treat the patients. Should they be done with the traditional open procedure, or the minimally invasive stenting? How do we decide? That's not always easy.
When it comes to some of the involved interventions that carry risk, which patients are going to live long enough, for example, to benefit from that surgery? Do we actually prolong their life by carrying out the surgery? These are two big questions where there isn't a huge amount of evidence yet.
I'm really excited about artificial intelligence and health data sciences research because that promises to answer these questions in a way that traditional research hasn't been able to. That's where some of the big advances will come. The other is the evolution of device technology. The stent grafts that we use have evolved a lot over the past decade.
I think they'll continue to evolve. The materials will evolve. There'll be, no doubt, new technological advances to make devices more durable and applicable to all sorts of anatomy, because there are currently anatomical restrictions as to how we can use some of these devices.
The third area is that if you use minimally invasive surgery it's all X-ray guided. There is consequently radiation exposure to both the operator and to the patient. We've done some research in our department to show that there is actually biological damage.
There is a biologically significant effect related to exposure both to the operator and to the patient. We are now seeing technology that promises to be able to allow stent procedures, and X-ray-guided procedures to be done without the use of X-ray any more.
Using fibre optics, using electromagnetic guidance to put these devices in - that's really an area both us and industry have to pursue, because the radiation exposure from these procedures is a real hazard.
How did you first become involved in research?
It started with an intercalated BSc in medical school. I did a BSc in anatomy, and enjoyed it. I did well during that BSc and then really just carried on the career path. I wasn't planning to do significant further research, or to be a career academic.
But I started working in the department where I'm now the professor, and I was mentored by a couple of people who suggested that research might be a good idea, and who introduced me to the then professor of vascular surgery in that department.
After talking with him and a few others, I decided to embark on a PhD - I surprised myself - but again, I really enjoyed the PhD. I got some very good outcomes from those three years. From there, the opportunity for an academic, clinical lectureship came along - I was appointed and the rest is history.
It was the opportunity to partake both in research and clinical that really attracted me, and because of the opportunities I had and the people that I worked with and was surrounded by, I had some good outputs. That all builds into a successful research programme that I'm grateful to be directing and to be part of.
What research are you currently involved in?
We carry out the full gamut of translational - and I have to stress 'translational' - basic science research to very clinical, data-related research. We're not interested in just carrying out research for the sake of it. It has to be close to the bedside for patient benefits. One of the areas is for patients with limb ischaemia who aren't amenable to the standard treatments such as angioplasty, stenting or bypass.
For those, for the past decade or more now, we’ve looked at angiogenic and atherogenic cells - so the cells we can inject to grow new blood vessels in these legs. We started in the laboratory identifying a novel cell type, and have translated that all the way into first in human studies. We hope to have a product that we will be able to assess in clinical trials shortly.
When it comes to more clinical type research, it's collating data, for example, from aortic repair and trying to find patterns as to what's the best way to repair patients with aortic disease, and what techniques work best. Regarding radiation research, again, that's something that's only possible when you have some basic science expertise.
What we did was isolate peripheral lymphocytes from both patients and operators. We used a technique called ‘flow cytometry’ to detect markers of DNA damage in those lymphocytes, and that was very impactful research that was well received from the Vascular Surgical Societies around the world and beyond. A big spectrum of work related to vascular disease.
How can people choose between basic science research or clinical research?
Some people are quite polarised in that they know they do not want to do basic science laboratory research, and that's fine. Some are much more interested in clinical research. You need to know in your heart of hearts what it is that interests you. I think that's a good starting point.
Beyond that, however, when you're starting out, you need to be advised into going down a pathway that would be fruitful to you. The one piece of advice I give everybody is that no matter how senior they are, or what position they are in, colleagues do not mind being approached.
If they are approached by somebody who has a genuine interest and wants to further that interest, then I can't think of many people who would not help, or ask a member of their team to help. That is the best starting point.
I would advise that before approaching anybody, you do some research into what the particular lab or person is interested in, what papers have they published, and what type of research might be possible for them to engage with. Ask if there is a track record of supporting students and then get involved in that way.
The INSPIRE programme that we run at KCL is very useful and provides tasters into research. We organise events, and have summer projects that colleagues can get engaged in. That's a more structured way of getting involved. There are plenty of opportunities at an institution like KCL.
What challenges do surgeons wanting an academic career face?
The first thing to say is that it's not easy, in that there are competing demands on your time, both as a trainee and as a qualified consultant. So being organised and being realistic about what a clinical academic can achieve are two very important things.
As a trainee, there is no doubt you have a shorter amount of time to get the clinical proficiencies that some other colleagues who are not academic do. Therefore, it requires real focus and good use of your time, but it is possible.
For example, as an academic clinical lecturer, during the more senior parts of your training, you move around between units less. That has its disadvantages, but it also has its advantages in that you don't have that same ‘familiarisation’ and ‘learning how things work’ type of cycle every year.
Therefore, that allows you greater opportunities for clinical training if you're in the same place for a period of time. The research setup has to be right. There has to be a team of people that can aid and advise, and perhaps help in some of the research work that needs to be done for a surgical academic.
Finally, it's all about focus. Perhaps not so much during training, but later on, as a qualified consultant, it is important to focus on both the clinical, and the research work you do. As a clinician, I do not think you can be a jack of all trades as a surgical academic and want to do open thoracoabdominal surgery, endovascular thoracoabdominal surgery, lower limb bypass surgery.
It just will not work. You have to focus on one particular area and do that very well. At the same time, have the general competencies. On the research side, you have to have a goal. Particularly early on, you can't have 100 different ideas and start going in ten different directions, as far as your research is concerned.
What bears fruits and brings outputs is being focussed again in one particular area, following it through with a grant income, developing a certain programme of work, building that into a meaningful manuscript - for example, publishing well - and then building on that in the following years. That's what I would advise. Drive, focus, and then mentorship, which is also very important to success.
You spent a year as a vascular fellow in Australia. How was vascular surgery there different?
The biggest difference was that it was in Sydney, and when you finish work you go to the beach, or drive for 40 minutes to the mountains. Comparing the experience in Sydney to Guy's and St Thomas', the first thing that struck me was the enormous volume of work that we do at Guy's and St Thomas'.
I mean the complexity and the volume of work that goes on in the vascular unit on a weekly basis. I've been to a lot of units now, and there aren't many places in the world that have that. Another difference is the system in Sydney. Most colleagues in Sydney worked part-time in the private sector and part-time in the NHS.
At that time - and this is a number of years ago - their vascular surgeons were much more at the forefront - particularly with the lower limb endovascular minimally invasive techniques. They had taken that in hand and developed it. At that stage that was not what the vascular surgeons were doing in the UK, but things have changed since.
We still work in harmony with our interventional radiologists, but, for example, at Guy's and St Thomas' the vascular surgeons also carry out independently the minimally invasive lower limb angioplasty and stenting.
When would you recommend doing a PhD during training?
The first - and the pragmatic - thing to say is that you do it when the best opportunity comes about. You have to decide that by assimilating all the information. When it comes to research, and throughout your career, you will hear voices from every single direction, and part of the key to success is being able to assimilate that and decide for yourself what is best.
The most important thing is that you get advice and mentorship from different directions, but at the end of it, you have to decide. Some of it comes down to opportunities that arise. I would advise that it's better to do a PhD when you are in the speciality that you're going to work in.
I say that, because you can then embed yourself within a unit that's going to forward not just your research career, but more than likely your clinical career as well. You know that you're going to be interested in that area. The expertise that you gather around that particular research topic, if it's in your speciality, will stand you in good stead later on.
There's no doubt that through that process of doing a three-year PhD, you build relationships, you find mentors, and you learn about the sphere that is your speciality later when you qualify. It's better to do it a little later than during medical school or foundations.
How do you go about identifying a mentor?
This is becoming increasingly a hot topic for clinical academics. Clinical academics succeeding. Clinical academics remaining in academia after they get an opportunity. It is a priority, and it is an area we have to work on, because in the past, the success rates have always not been good, when we look at it on a national scale.
The feeling now is that mentorship can go a long way to facilitate the progress and success of clinical academics. Traditionally, it's been ad-hoc. One of your senior colleagues suggests somebody they know who fits the profile of somebody that might mentor you. I just wonder whether mentorship should be a lot more structured.
Why don't we have a resource of people who are happy to sign up to being mentors? I know that bodies such as the Academy of Medical Sciences run schemes such as this. There's no reason why we can't have a more joined up, speciality specific scheme, or schemes at King's pertaining to specific streams, where we build a group of mentors that colleagues can choose from.
Perhaps you need to have both clinical and academic mentors that are labelled as such, and who, in a structured way, help you through whatever endeavours you're engaged in. To have regular sit-downs every few months to write a structured report on where the needs are, and also to liaise with the clinical training programmes.
That's important for clinical academics because they sometimes need guidance, when it comes to communicating with our colleagues who run the clinical training programmes, on what their progress is, and what their needs are. To have an independent advocate for that would be quite useful.
What would make you want to mentor someone?
For me, it's somebody who is genuinely interested, who is hungry for success, and who is respectful of the process and what it involves. To do the piece of work or the endeavour that they're engaged in. Genuine interest, enthusiasm, work ethic, and taking on board advice and guidance.
Once you see that you're dealing with somebody like that, who listens, is willing to work hard to get to where they want to get to, and is ambitious, then it's a real joy to support that.
What tips can you could offer on pursuing a career in vascular surgery?
Early exposure to vascular surgery is important. Now, with the way that progress through medical school is structured, it's not always easy to get that exposure. Even back when I trained, we got exposure to surgery quite early.
For me, it was very important to know that what I was thinking was the right thing to do, actually was the right thing to do. Having practical experience on the ground is quite important. Seek out the vascular surgeons in your institution and ask to shadow procedures. Ask what research goes on. Ask what the day-to-day reality of life as a vascular surgeon is.
Then, from an early stage, get involved in a project that's being done, whether it be an audit or a clinical research project. Even if you're not leading it, if you contribute something to it, then it shows that you've got a genuine interest.
If somebody who is motivated, hardworking and genuinely interested approaches you to get involved, the vast majority of my colleagues will not say no.
What has shaped you as a clinician and researcher?
I'll start with the clinical side. Your expertise evolves as time goes by. I was very fortunate in that as a young surgeon, I was supported by more experienced older colleagues. That is equally, if not more important for the new generation coming through now.
Even when you think you know it all, that you can do it all, there is still so much to learn, and it's very important to have the support as you travel through. I look back to when I first started as a consultant and the experience counts for a lot, and you learn a lot along the way and modify the way that you operate.
That's very important to bear in mind. And you never stop learning. It's a cliché, but it is true. On the research side of things, the most important thing is focus - communicating with people about opportunities, what they think, and how they can facilitate. Don't hesitate to approach people and ask for help because that brings you opportunities.
When you need to, you have to work hard. There are times when the opportunities present themselves and you have to focus 100% on getting them done, because if you succeed in those opportunities, then that builds, and things go forward.
What habits have you developed to help you cope?
Things can be difficult. Some of it is practice, I guess. You get conditioned as time goes by and you're then better able to deal with stress and the different commitments. You almost train into multi-tasking and dealing better with those things.
It's about prioritising and it's about patient care being first and foremost. At the end of the day, without being able to operate, without being able to look after patients, you have no kudos as a researcher.
Being a clinical academic surgeon has to involve being very good at the particular clinical discipline that you choose, and always putting patients first. That would be my advice.
How do you maintain a healthy work-life balance?
I have a family, and that's useful because it brings a whole different perspective to life. Things are getting better as far as work-life balance is concerned. The way that your week is structured is monitored. If there are strains, then there are things that can be done to change that.
Another big difference is that there are a number of colleagues who are working as consultants in our unit. In the past that wasn't always the way. Nowadays, there's a greater realisation that a proper work-life balance is a must, and the patterns of employment acknowledge that. That makes things easier.
In reality, when you're off, sometimes you do have to do some extra work because of deadlines, but you mustn't let that become a habit. Weekends should be weekends that you spend with family, and doing other things.
There has to be the realisation that if you're working all the time, it's counterproductive. You're not going to produce the same quality of work unless you give yourself a break from time to time. For me, it's spending time with family, friends, and going to the beach in Cornwall.
Do you have any role models who inspired you personally?
For me, the biggest role models were those who were highly effective surgeons, who were very good at what they did, but also kind and measured. Not necessarily those who made a lot of noise and were disruptive, but those who were effortlessly good and demanded respect because of how they behaved. Those are the role models that everybody should aspire to.
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.