Professor Francesco Rubino, Chair of Metabolic and Bariatric Surgery, King's College London

Published on: 13 Oct 2022
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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.

Today, the subject is professor Francesco Rubino, who is chair of metabolic and bariatric surgery at King's College London. Professor Rubino became the world's first professor of metabolic surgery. He conducted pioneering research, which provided the first experimental evidence that bariatric surgery can improve diabetes independently of weight loss. This evidence provided scientific rationale for the surgical treatment of type 2 diabetes.

A podcast of this interview is available here:

 

How did you get to where you are today?

It's been a long journey. It started in Italy, where I was born. During my adolescent years I started to contemplate a career in medicine. I had other interests as well. 

So, on and off I was thinking about a career in medicine or as a football player, but eventually medicine took over. I've trained and practised in different countries. I came to the UK in 2013, and since then I've been at King's.

 

What attracted you to bariatric surgery? 

This was really one of the oddest things in my life and in my career. I was interested in surgery, although I thought this would mean I would lose the research and discovery aspects of medicine. I thought in surgery everything was well-known. 

I was also thinking about a possible sub-specialty in surgical oncology or other surgical specialties. I wasn't sure which career path to take. But the only thing I was sure about was that I would have never become a bariatric surgeon. 

Instead, I went on to become the first professor of bariatric surgery. When King's, in 2013, established a chair in bariatric surgery, that was the first time any university had established an independent, distinct academic chair on this particular subject and discipline. 

In the past, bariatric surgery had been a subspecialty of general surgery, but not an independent academic discipline. So it's quite odd that somebody who did not want to be a bariatric surgeon ends up being a professor of bariatric surgery. 

 

Stigma is a big issue within both obesity and diabetes. How can we combat it? 

Stigma is one of the biggest problems we have in obesity. Weight stigma is widespread. One of the reasons I became interested in this is because I came to realise that nobody is immune to weight stigma, including myself. 

I did not want to be a bariatric surgeon - I thought that was not a career I would choose. That was because of my stigmatising people with obesity. I thought they were responsible for their disease - not unlike most of us - and that operating for obesity was not the right answer. 

I thought obesity was something people can do and undo as they wish. That was a mistake that I recognised. I realised others were doing the same. I also realised how many things could be altered by this weight stigma, including my own career. 

Most importantly, stigma is affecting the lives of many people -, the way they receive or don't receive medical care, and the fact that they are discriminated against in society, and bullied at school. The damage of weight stigma is so huge and the stigma is so pervasive that I believe it's the single most important problem we have in medicine today. 

 

What are some common misconceptions about obesity?

A common misconception is that obesity is a ‘lifestyle choice’. People even use this definition without thinking about what that implies. To be a ‘choice’ implies that people can choose to have obesity or not, and that is entirely contrary to science. 

We know that obesity is not just as simple as eating too much, or not exercising enough - that's the conventional narrative that blames the individual for their obesity. Science accumulated over many decades shows that the way body weight is regulated has very little to do with intentional decisions and actions, and much more to do with biological mechanisms that are below the level of the brain where normally we control willpower. 

For instance, many of the weight regulation centres are located in the hypothalamus, and not the cortex, where we have our centres that control our willpower decisions. So there is a big disconnect between what we know from science and what the biological regulation of body weight is, and what the conventional narrative of why people gain weight in the first place is, or why people don't lose weight. They cannot lose weight. 

People who cannot lose weight are blamed for not doing enough. There's no such evidence, and this is one of the biggest gaps between what science shows and what people think. We need to make sure that gap is addressed, because otherwise we will continue to have misconceptions that fuel stigma. 

 

Tell us about your experience being a surgeon in different countries? 

My life has brought me to Italy, where I was born and trained at medical school in my early years of specialising in general surgery, to the United States, where I also trained, and then to France where I continued my advance training after finishing my specialty. 

I’ve also had the opportunity to work in the United States, France and Italy, and for seven years in the UK.  So I can tell you that there is no perfect healthcare system. There are weaknesses and strengths in all of them. 

When people ask me: ‘What is the best healthcare system?’, I answer that it's perhaps somewhere in the middle of the Atlantic Ocean. So, it's not entirely in America, and it's not entirely in Europe or in the UK. 

There are strengths to each of the systems. I like the fact that in my home country of Italy there is still some sense of health being a human right, and that health is actually defended in the constitution of the country. 

That is a strength quite unique to that country, because it has a lot of ramifications in the way that not only we deliver care, but also in the healthcare policies that are envisioned.  The UK has many strengths. It's a country of excellent academic prestige. And we have an NHS - many countries don't. 

Overall in the UK, there is a sense that evidence-based scientific evidence is important in making decisions for clinical practice. The UK has been leading the way for many years in the development of this idea of evidence-based medicine. I've learned a lot from each of these countries where I practised. And I've been comfortable in practising in all of them.  

 

How did you build a successful career as a surgeon in America? 

I had an experience in America in terms of training. I went there for fellowships and to learn about minimal invasive surgery. I then came back to Italy, but returned to America for a position as an ‘attending’ (a consultant), and associate professor at Cornell. 

America remains very much the land of opportunities in the medical field. Perhaps I couldn’t have realised the things I've done in the early phase of my career if I was in Italy or France, where I also trained and practised. America gives young people more opportunities than they would have on ‘this side of the pond’. 

You don't have to be old to be listened to. You can have an idea, you can publish with your name first, you can go ahead and get important positions - even early on. I went on to become chief of metabolic surgery in a major US hospital in New York City, at an age where my colleagues in Italy were still not even close to reaching that level of responsibility.

I think America still has an edge on giving opportunities early in the careers of people who want to deliver and pursue a dream of becoming a scientist or a clinician. It's a great place to train and work early on in your career. 

It's not easy - you have to pass exams in order for America to recognise your medical degrees. The sooner you apply for the USMLE test the better - as soon as you finish medical school - because many of the questions that are asked in those tests actually refer to biology, chemistry and things that you study in the first years of medicine. 

The later you do this test, the more likely you will have to study, because things change over the years. So, if you intend to go to America, take the test sooner rather than later. Then, consider the option of potentially specialising there, if you want to pursue a career there. 

 

So you had your residency in Italy, then moved to America to take the fellowship? 

Yes - my story is quite an outlier, because I took the USMLE, then some fellowship training in America, but I didn't specialise formally there - I kept my specialisation in Italy. 

The reason why my specialty was then recognised was because when people tried to recruit me in New York, they felt that I specialised in metabolic surgery - a new discipline - or surgical treatment of type 2 diabetes. At that point, this was so new that there were not enough surgeons in America with that type of expertise. 

So, I was given a full licence in the State of New York, based on the fact that I had practised this discipline myself for many years in Italy and France. It is said that this is equivalent to having specialised, especially given the fact that there isn't such specific training. Today, it's a different story - metabolic surgery is a recognised specialty. 

 

What led you to leave the US and come back to the UK? 

There are a number of reasons why you make such a move. I was contemplating other options in the US as well, in other big hospitals. All these opportunities were quite interesting to me, and also flattering in terms of progression of career. 

What really attracted me from an academic standpoint is that King's is a prestigious university, and the fact that they were contemplating establishing a new chair in the field that didn't have any academic recognition before. 

In fact, it was the culmination of a career where I was one of the people who, from the early 2000s, started to promote the idea of metabolic surgery, and seeing that being recognised formally, with an academic chair was appealing. 

Another attraction was that I had always been very vocal about the fact that there is such a thing as surgical treatment of diabetes. It's now a reality, but back then it wasn't even conceivable to think about operating on diabetes. 

So, the fact that the chair of metabolic surgery was actually within the diabetes department was very attractive. It resonates with my idea that there isn't such a thing as a surgical disease or a medical disease - there are diseases and there are treatments. 

So here was a surgical programme that could be under the department of diabetes, and was breaking down those barriers that I was hoping to break with my own initiatives. 

Family was a very important reason. My parents in Italy, particularly my mother, were ill, and they would have not been able to continue to come visit me in America. Being in London, you're close to everything, you're very close to Italy, and I could visit my parents more often. 

I don't regret that choice because my mother unfortunately passed away a couple of years ago, and I would have not had the opportunity to just jump on a plane and see her as I have in the last years of her life. It was a blessing for me to have that opportunity.

 

How did you first become involved in research?

I had this idea that medicine is about two things. One is treating the person - the patient who comes to see you - but also, through research, you may touch, and positively influence the life of people who you never see. I think that's what research is about. 

Through your research you can advance a solution to a problem or question. People and patients around the world will benefit from your work, even if you never get to see them. I think that's an exciting part of being a clinician scientist, and that's the reason for my interest in research, not just for clinical care. 

At the beginning of my career I was concerned about a potential clash with becoming a surgeon. So pursuing this aspiration of being immediately helpful to a patient with a surgical intervention gives you the most immediate sense of how your action can improve someone’s life. It's not even mediated indirectly by a drug, it's just a direct relationship. 

There's a strong relationship with the patient - that sense of closeness - and I really wanted to experience that. I was afraid that going into a surgical career, I would never be able to do research - or at least the type of research that leads to discoveries. 

At the end of my medical school, I thought, mistakenly, that in surgery everything is known now. The anatomy is well-known, the type of physiology you need for doing an operation is quite well-known, and the procedures were already standardised, so all you need to do is to apply them - there is not much to discover. 

So, I took surgery eventually with a bit of reluctance, because I said: ‘ I'm going to pursue the interest of getting close to patients and do something for their lives, but I will give up the aspiration of discovering anything new!’ I couldn't have been more wrong, because in fact there is nothing now that we do - let alone in medicine - that is forever.

Things can change. As you approach things with critical thinking, you realise there are so many questions that are unanswered - and trying to answer questions is the fundamental meaning of research. 

So, there was research to be done in surgery. I was particularly intrigued by the questions that arise from seeing how some patients who had bariatric operations would immediately see a resolution of their diabetes. 

I found there was something so odd that couldn't be answered by the conventional explanations we were giving about diabetes or obesity. That oddity was a significant driver for my research. In fact, that's how I became a clinician scientist, not just a clinician. 

 

Tell us how you pioneered the use of bariatric surgery for the treatment of type 2 diabetes? 

This was by chance. I was one of a new group of  fellows at Mount Sinai Medical Centre in New York City. My mentor told us one evening at dinner that the following day he would be doing a ‘surgical first’. 

He would be doing the first minimal invasive keyhole approach to a complex bariatric operation. He did that the next day. We were all excited to have witnessed a ‘first’ in surgery. It was a technical feat. 

Normally, with anything to do with biology or other questions, because the operation was well-standardised in open surgery, all that was needed was a technical advance in reproducing the same operation with a minimal invasive approach. 

I asked my mentor: ‘Why did he have to do the operation in a certain way?’, because that included the use of too many staples that would make the cost of this operation too expensive to be afforded in many countries. 

He said: 'This is the way the operation has been described and developed. But go to the library,  see who invented this operation, and why they made it this way, and if it can be done differently’.

So, I went to the library to answer that technical question. All of a sudden, I found a table in a paper published by the inventor of that operation, and in this table there were the laboratory values of about 2,000 patients who had  had that operation one month before. There was a one-month postoperative outcome in 2,000 patients who had this operation. 

When you looked at it, one line was glycaemia, and it was normal in nearly 100% of those people. I browsed the page, because that was not what I was really looking for, I was looking for something else.  

And then I came back to that table and said: ‘This is odd - 2,000 people had undergone this operation - all of them with severe obesity, many of them who must have had diabetes to start with - how could it be that nobody has diabetes one month after the operation? 

I knew that weight loss could be a factor in improving diabetes, but from having diabetes to not having any sign of diabetes in a month? These patients are not going to lose that weight in a month. Most of them are still going to remain in the obesity range. If obesity is the cause of diabetes, why is it that the diabetes disappears before obesity does? 

All these questions, and there was no answer for me. I said to myself: ‘What if it is the surgery on the gut that is actually changing diabetes for whatever reason? And if that is true, then everything we know about diabetes would have to be reconsidered.’  

I was so excited. I couldn't sleep that night, at the very idea that if you have such a direct influence of an operation on the gut on diabetes, then diabetes might be something different to what we thought. 

Not only could you operate on diabetes - which is obviously one consequence - but most important and consequential is the fact that if that organ you are operating on is so crucial to induce a complete disappearance of the disease, it might also be crucial to induce the disease in the first place. 

So, I started to think whether or not diabetes could be, at least in part, a disease of the bowel. That, to me, still makes sense, because it would explain not only why surgery works, but why modern diets could actually cause an epidemic of the disease. 

If you think about modern diets changing the functioning of the gut, that's very likely, because the gut is the first line of contact with what comes with foodborne factors. So that would be a critical link between modern diets and epidemics of obesity - maybe even more so than this traditional idea that we are getting heavier, hence we are getting diabetes. 

The possibility is that we are eating something that changes the physiology of our gut and causes dysfunction in sugar metabolism, hence we develop diabetes. That's the hypothesis I've been working at for the past 20 years. 

 

From this discovery, you conducted a trial in bariatric surgery for diabetes. Can you tell us about this work? 

In 1999, when I felt there could be something interesting about what surgery does to diabetes, I ran to my mentor's office. I said: 'What if surgery could improve diabetes directly, and not necessarily in people who are just very severely obese, but maybe even people with less severe obesity?' 

To his credit, I was lucky, because sometimes mentors would say: ‘This is crazy, just forget about it’. He said: 'I don't know, how can you answer that question?' I said: 'Maybe we can answer that question by doing two things: one is to do a study, maybe in animals that have diabetes, and we could try an operation and see if it works. 

Another could be to do a clinical trial where we use surgery in people who have diabetes, but perhaps they don't have as much severe obesity as the ones that normally have bariatric surgery’. 

My mentor thought that we could do both things. He asked me to immediately submit a protocol for a clinical trial, like the one we just published recently - the ten-year outcomes in The Lancet. 

Back in 1999, when we submitted the protocol to the Ethics Committee of Mount Sinai, they came back to us and said: 'You are out of your mind’. They did not approve the trial because they said it was not conceivable to use an operation to treat diabetes. The reason being is that it’s said that diabetes is a systemic disease. 

So how can you operate for a disease that is systemic - which means it affects many organs and has no known organ where it sits - and use an operation to treat this disease where the operation is an organ-focused or organ-specific intervention? So, it was inconceivable to do a clinical trial as recently as 1999. 

Then it took a bit of work to put together a number of experts from around the world looking at the early evidence and to do the studies, first in animals to prove the concept, and to finally get this type of trial accepted by the ethical committees. 

One of them was a trial with my colleague, Geltrude Mingrone, who is professor of medicine in Rome and also King's. Together we designed this study at the Catholic University of Rome. I went from New York, where I was at that time, to Rome to operate on some of these patients. 

The bottom line is that the trial, like other similar trials, has been consistently showing the superiority of surgical treatment compared to any treatment we know of for diabetes. At the moment, the evidence is overwhelmingly clear that you can reverse diabetes, but also improve it far more efficiently and far more significantly, with a surgical operation than with any medications available today. 

That doesn't mean we should operate on everybody with diabetes, but it means that surgery can be an extraordinary way of treating it, especially in people who might be at risk of severe cardiovascular disease or death from diabetes. These operations can be life-saving for many patients. 

You consistently proved the efficacy of bariatric surgery in numerous trials for the treatment of type 2 diabetes. When will this become part of the guidelines? 

Over the past ten years, we had at least 12 randomised trials, at least 11 more in addition to the one when I was involved with Dr Mingrone and colleagues, and all of them have been quite consistent. 

Besides the clinical trials, the randomised trials, there are also many other studies with larger populations and case studies that show a reduction of mortality from diabetes, and a reduction of cardiovascular disease from diabetes. 

Because of all the bulk of this evidence, in 2015, global guidelines were changed. This was thanks to the Diabetes Surgery Summit, an event that we organised with King's in 2015, where we looked at the evidence and developed new recommendations. 

These recommendations and clinical guidelines have been approved and endorsed by over 56 diabetes organisations from around the world, including the American Diabetes Association, Diabetes UK, and many others. 

So, today, operating on diabetes is a standard of care, and that's a huge change. It's one of those changes that, if I look back at the early years when this was merely an idea, and now looking at the fact that most diabetes organisations put surgery in the algorithm of diabetes management, it's like a dream that came true. 

 

What about the cost-effectiveness of bariatric surgery for treatment of diabetes? 

Bariatric surgery is cost-effective across the board, even in patients without diabetes. But in patients with diabetes, this operation is even more cost-effective. Type 2 diabetes is a disease that often requires complex medical management - not just one drug, but more drugs, and sometimes insulin. 

Many patients require insulin, even if it's type 2 diabetes. On top of that, patients with diabetes require frequent monitoring and check-ups. Unfortunately, they also develop complications, like renal, eye and cardiovascular complications. 

So, their healthcare utilisation, because of diabetes-related complications, is quite high in people with type 2 diabetes. Now, if you imagine that this type of surgical operation on the gastrointestinal tract can very rapidly reduce the need for medications - an 80 % drop in medication usage by three months from surgery and even earlier - then you can understand how you can start saving on very expensive medications that otherwise would need to be taken every day. 

Diabetes not only needs medication for hyperglycaemia, but very often people with diabetes also have hypertension and dyslipidaemia, and they take medications for those conditions. Those conditions are also ameliorated by surgery, and so you also drop those medications as well. 

So, it's quite cost-effective right away. Also, what we're seeing now, including in the trial we published in The Lancet, is that in the long-term, surgery reduces the incidence of diabetes-related complications, including myocardial infarction or renal disease or other things that are very expensive to treat otherwise.

So there is both a short-term and a long-term cost-effectiveness in using surgery for diabetes. 

 

You are the world's first professor of metabolic surgery. Where do you see your research going over the next five to ten years?

In terms of surgery, I've been very vocal about the need to distinguish between metabolic and bariatric surgery, the reason being that bariatric surgery, for many years, has been practised as a surgical treatment of obesity. 

There are many advantages in doing that, because obesity itself is a significant problem and disease for many patients who need treatment. Operating for diabetes is a completely different story, because the way you prepare patients for surgery, the type of surgical procedures that you choose, and the way you manage patients postoperatively changes, because it's the disease that is changed. 

Historically, when we performed bariatric surgery, we have focused on this weight loss surgery concept. So, everything is focused on weight, including the type of monitoring and postoperative follow-up. You look at weight loss outcomes more than you look at other things. 

One of the reasons why I believe - despite decades of experience of surgery and diabetes getting better - there wasn't much action, is because some of these outcomes were not necessarily studied, investigated,  presented, and emphasised as they should have been. 

The care of people with diabetes is significantly different than people without diabetes, and metabolic surgery is a different model of care that needs to be used for these patients. 

What is the future? What we're starting to see is not only that type 2 diabetes responds to gastrointestinal operations dramatically, but other metabolic illnesses associated with obesity respond dramatically too. 

One in particular is NASH - a conventionally fatty liver disease. NASH is a non-alcoholic, chronic liver disease that unfortunately is associated with insulin-resistance, with a similar biological background to type 2 diabetes. It’s very common in people with diabetes. 

It's a disease in itself that can cause cirrhosis, that can lead to liver cancer, and that can require the need for a liver transplant in the future. It’s a major issue in our society in terms of prevalence and consequences. What we have seen is that NASH also improves quite dramatically after this operation. 

I think in the future this could become another indication to metabolic surgery in itself. At the moment, there aren't many options for people who have NASH, other than recommending them to lose weight, except of course that's very difficult. 

So, we do have a treatment that could work. But, again, as it was for diabetes, because it wasn't invented for NASH, or it wasn't invented for diabetes, we have this delay in recognising opportunities and valuable treatments due to the way that we're framed at the beginning. 

Because bariatric surgery was framed as a weight loss intervention, for too many years it has not been used as a metabolic intervention for diabetes, or for NASH, as I hope it will in the future. We need to conceptually change the way we look at bariatric surgery and understand that it's just a surgery. And we'll have to understand which diseases make an indication for this type of intervention. 

 

Can you tell us about your criticisms of the traditional bench to bedside approach to clinical research?

For me, especially in the second phase of the 20th century, we have always spoken about this idea of a ‘bench to bedside’ approach to medical research. It’s a way to translate discoveries that are made at the bench-side, or mechanisms that are investigated and developed at bench-side level, and to make sure that they are fast-tracked to become a clinical application at some point. 

That's the intent. But I think that unfortunately this description creates a misconception that you could potentially, effectively, or efficiently, develop something of clinical interest from a laboratory. Whereas if you look at the history of medicine, we have always made our best discoveries and advances by understanding the clinical needs, or raising clinical questions, or making observations that lead to research at bench-side, and then back to bedside again. 

My ideal model of medical research is from bedside to bench, and back to bedside. Particularly for what pertains to my field of metabolic surgery, you can see that starting from a clinical observation, there's an extraordinary disappearance of diabetes after an operation on your gut. 

Going to the bench to understand how surgery works, and why an operation on the gut transforms type 2 diabetes in a way that we have never seen before. Then, develop at the bench-side the translation of research and new ways of mimicking what surgery does. 

So when you go back to the clinic with a new drug or a new device or a new operation, you are much more likely to see that invention to be clinically effective, because it comes from an experience in the clinic where it was effective.

Another thing similar to this is that we figure it out, and now we go back. If you're just going to molecular biology, you pick up a pathway and say: ‘I think this is important - go to bench and see if you can make a drug’. Then you bring that drug to the clinic. 

Often that drug doesn't deliver on the promises that you had at the level of bench-side, simply because there is a missing link with the clinical efficacy or clinical issues being addressed. So, I think 21st century medical research should become more ‘bedside to bench’, and then ‘back to the bedside’. 

 

What advice would you offer to medical students and doctors who are interested in research? 

I think to be a successful researcher, you should probably not necessarily focus on what kind of research is important. What you should focus on is what questions need an answer. That will tell you what research is important. 

Sometimes we tend to be involved in medical research and are trying to pursue research avenues that might actually be either not leading anywhere, or not making us feel passionate about it. I think you would feel very passionate about doing research if there is a question that you cannot answer with the current state of knowledge. 

That is the drive to address that question, and that is the drive to make you feel passionate about doing research. It's also the reason that makes your efforts more likely to be meaningful, because if you do address a question that exists, then your answer to that question is likely to have a clinical impact. 

If it's a hypothetical research that follows on to something, but as a fundamental clinical question, I think it's unlikely to determine major advances. 

 

What are some of your proudest achievements? 

There are many things that happen in the careers of each of us - small events or more important ones where we feel accomplished, or feel the reward for the many sacrifices that we make. All of us, when we go through medical school in this career, know it's not easy, and that it needs a lot of dedication and effort. 

So, what could be a major accomplishment? There is an event in my life, and my profession, that epitomises to me what it means to be a medical doctor. It is something I experienced relatively recently. 

My mother was terminally ill in the South of Italy. She was in a facility where, when she needed a bedside manoeuvre, the doctor wasn't experienced to do it and couldn't alleviate her pain, which was quite substantial. So, they asked for a specialist to come from outside the facility, but it couldn't happen before the late evening. 

I flew back home to Italy. When I entered my mother's room, she couldn't even speak, but she looked at me with the eyes of somebody who was in pain and in fear, but had seen a familiar face who could bring an end to that suffering. When I did the manoeuvre and successfully alleviated her pain, I felt like all my medical school years, all my learning, were worth it just for that alone. 

If you translate this to more broad considerations, I think that's exactly the patient-doctor relationship. Patients are people who are in fear because of their pain, and they're looking for a familiar face, somebody who is on their side, to alleviate that. 

The sense of relief that they have, of feeling better and stronger, comes from the fact that they know somebody will take care of them, and it's somebody who is sympathetic. They share the feelings and they work to the same goal. 

Whether you're taking care of your mum or anyone else, everybody is a mum, everybody is a dad, everybody is a brother or a sister, siblings and friends. Patients look at us with the same eyes as my mother looked at me when I entered that room, and I think this is what makes our job as doctors so important, but also so rewarding. 

If you keep that sense of recognising that there is a mother behind any patient you treat, you have an ‘edge’ in working in a profession that is very difficult at times, and also very burdening. But you keep that passion because you know it's relevant and you need to see those eyes in everybody you treat. 

It’s important to maintain the passion that you had since the beginning of medical school for the rest of your career. The secret to being a successful doctor is to maintain that early passion that each of us had when we started medical school. We want to do good, we want to help people, and we have to make sure that passion, that feeling, never goes away, never fades, because that's what keeps us going. 

 

What advice would you offer medical students and doctors just starting their careers on how to be successful? 

You should listen to yourself and what makes you passionate about something. This is a profession that will give everybody difficult times here and there. There will be setbacks, disappointments, hard times, and efforts you need to make, sometimes beyond what you think is possible. 

The only thing that keeps you going is the feeling that what you do is important and does good to other people - but also something that can keep you passionate. It's your passion that will make you overcome any sacrifice. Nothing will be too difficult for you to overcome if you are passionate about it. 

The moment you start feeling bored about something is when you start not being able to overcome obstacles and succeed. So, if you have to choose a path for your career, follow your passion, even when this passion arises from an idea or an experience that you would have not predicted. Follow your heart. 

You might have planned your career as an orthopaedic surgeon but then discover that cardiology is the one thing that really makes you passionate. Follow your passion. Forget about whether or not it's easy to find a job in that discipline, or if it's more remunerative, because all those rational things are only rational for today. 

In a career path that lasts for decades, whatever consideration you have today might actually not last very long. But your passion might last, and if it does, you will be successful. 

 

Who have been role models during your career? 

I was lucky that some of my mentors were extraordinary role models. I'm fortunate that if I didn't deliver a certain minimum productivity in my career, it would have been my fault, because with the mentors I had, I would have lost an opportunity. 

I think you need to look at your mentors, to pick your mentors. You have to have somebody who inspires you. You have to have a mentor who not only has the expertise and the skills that can be transferred to you, but also somebody who has a drive that resonates with you, who practises medicine in the way you feel like you want to. 

Somebody who also has the ability to make you more open-minded. When I had this idea about surgery as a potential treatment for diabetes, I approached my mentor and said: 'I think surgery treats diabetes because it is changing the gut physiology, and not because you are losing weight.' 

Most potential mentors would have told me to stay quiet and said : ‘You're out of your mind, go home’. He said to me something like: 'I don't know if you're right or wrong. What I can say is: you want to do an experiment? Let's do it and see what happens’. So, 'let's do it and see what happens' is what really inspired me, because that's the meaning of science. 

Nothing should be set in stone. Nothing of what we know is forever. If you have a reasonable doubt that something might not be the way you've been told, then don't hesitate to critically question those things, and address the questions you have with experiments, or critical thinking if necessary. ‘Let’s do it and see what happens' is what I believe to be the sense of medical research. 

 

You played semi-professional football at a young age. Do you still have time for sports now? 

I feel a bit ashamed that I don't. A lot of my friends say: 'How could it be that you were so much into football, and now you're not leaving your desk for even a little run?'

I'm not playing football unfortunately, but I watch plenty of it, to the dismay of my wife for the many hours I spend watching Italian football or even Premier League football! But unfortunately, I don't practise anymore.

 

What's your favourite book? 

There are many books that have inspired me, but often I go back to the books of Gabriel Garcia Márquez. I like One Hundred Years of Solitude and Love In Times of Cholera.

I also like No One Writes to the Colonel. It's one of the least known of Márquez's books, but it's quite interesting because of what it implies, and how sometimes we forget about people and what they've done in the late phase of their lives. It's an interesting story. 

 

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.