Professor Keyoumars Ashkan, Professor of Neurosurgery, King's College Hospital, London

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 Keyoumars Ashkan, professor of neurosurgery, at King's College Hospital in London. Professor Ashkan has a special interest in functional neurosurgery, image-guided surgery, and surgery for brain and spinal tumours. He is president of the British Society for Stereotactic and Functional Neurosurgery, and lead for the Genomics England programme for brain tumours.

A podcast of this interview is available here:

 

How did you get to where you are today?

I was born in Iran, and moved to the UK when I was 15 years old. It was a bit of a journey - different culture, different language. I had to learn English in three weeks - enough to sit my O levels - so that was challenging, but I did it.  

I did my A levels, and then went to university in Cardiff - I had a wonderful few years there. I did my medical degree, and also an intercalated BSc in biochemistry there. I really enjoyed my time, and loved medicine, the city, and my fellow students. I have really fantastic memories of this time. I stayed on for my house jobs in Cardiff. 

I did professor of medicine and professor of surgery house jobs, which was challenging, but fun. I learned a lot, and saw lots of  interesting things. I then decided to move to London for my postgraduate training. I did medicine before I did surgery, because I don't really believe in these artificial barriers between different disciplines. 

I think everything is medicine. As human beings, we love categorising things. I much prefer to have an open sight, and follow my dreams, rather than be limited to different barriers and boundaries. I did the so-called ‘golden rotation’ in medicine - so Hammersmith, Brompton and Queen Square. I took my MCRP, and then I moved to surgical training. 

I did my FRCS after that, and then did my post-graduate training in neurosurgery in the South Thames rotation. I did part of my training at King's, and went to Brighton, to Hayward's Heath for a year. I then ventured up to North Thames for a year - so Queen Square and Great Ormond Street. 

Then I did my fellowship in functional neurosurgery in France, to learn the technique of deep brain stimulation from the master, Professor Benabid, who invented the procedure. You couldn't learn it from a better person. I came back to the UK, finished my SpR training, and was then appointed as a senior lecturer at National Hospital in Queen Square, where I stayed for two years.

I then moved to King's around 15 years ago, to take up a consultant neurosurgeon and honorary senior lecturer job. After a few years I was promoted to professorship. About eight years ago, I got my first professorship. So in a nutshell, a busy career!

 

What attracted you to neurosurgery?

Neurosurgeons are two different types. There are those people who love surgery, and out of all the various disciplines within surgery, they prefer neurosurgery, because they have a particular attraction to the skills involved, the patient group, or the discipline itself. 

There are also the other types of neurosurgeons, whose primary love or interest is neuroscience, so they love to understand how the brain works. Out of all the different neuroscience disciplines, they prefer to do surgery. I am definitely in the second category. If I wasn't doing neurosurgery, I would be doing something else neuro. You wouldn't catch me doing orthopaedics, urology or general surgery. 

My commitment is to understand the brain, and out of all the different brain disciplines - neuroradiology, neuropathology, neurology, basic neuroscience - I prefer neurosurgery, because it has particular areas that interest me, and it suits my personality. I'm a neuroscientist with an interest in surgery.

 

What are the biggest changes you have witnessed?

I spend most of my life doing two different types of neurosurgery. Half my time is doing functional neurosurgery - deep brain stimulation - and the other half is doing oncological surgery - so brain tumours. In terms of neuro-oncology, the biggest change - and there have been many in the last 20 years since I have been involved - has been the change in the attitude of neurosurgeons and clinicians towards managing patients with brain tumours. 

As a trainee it wasn't uncommon to be minimalistic in the approach to managing brain tumour patients, because part of the attitude was that: 'The prognosis is poor, so should we actually spend all this time and effort, because we will achieve “not so much”’. If you have that attitude, it's a self-fulfilling prophecy. 

If you don't go that extra mile, you're not going to get that extra result - which is what has completely changed. The attitude now is towards being able to do as much as we can - not just because we want to do this, but because our patients deserve to have the best service given to them to provide them with the best quality of life for as long as possible. 

Everything else we do - all the various technological tools we use, all the different ways we configure our services - is because of that fundamental change in attitude - that whatever we do is worth it, and that we have to go that extra mile for our patients. That's in the neuro-oncology field. With functional neurosurgery/deep brain stimulation, it's the technology. 

The technology has exploded during the last 15 to 20 years. The number of different types of tools, electrodes, batteries, all the different surgical tools that we can implant to the patient to change the function of the neural tissue - there has been a massive improvement in the last decade or so. 

It's an exciting area to be in, and to be able to play with all these amazing ‘toys’ that really change patients' lives.

 

What is functional neurosurgery?

When people think about surgery, they think about a procedure that changes anatomy. Surgery is essentially synonymous with the word ‘anatomy’. Functional surgery is totally different. You don't operate to change the anatomy of the body. You operate to change the physiology of the body. 

So the aim is to change the function with minimal effect on the gross anatomy of the structure. For example, ‘deep brain stimulation’, is a means whereby you introduce tiny electrodes, 1.3 millimetres in diameter, all the way from the surface to the various structures deep inside the brain. 

So thalamus, subthalamic nucleus, all those structures that you learnt during neuroanatomy in the first two years of medical school. By placing these electrodes in these deep targeted structures, and then connecting them to a battery pacemaker - very similar to a cardiac pacemaker - you send electric signals. You neuro-modulate. You change the function of the brain. 

All neural tissues work on the basis of action potential. It's all about electricity. Everything is electrical, so that's what you are doing. You're using electricity to change the function of the brain. And you can do the same thing, not just for the brain. 

You can do spinal cord stimulation, so you put electrodes on top of the spinal cord, and change the function of the spinal cord, for example, for severe intractable pain. Some students may be surprised to hear that we manage back pain with these kinds of procedures. 

You can really change the function of any neural tissue, whether it is a peripheral nerve, cranial nerve, spinal cord, or all the way to the brain itself, by introducing these electrodes. It's fascinating to be able to do this.

 

You famously operated on an awake patient playing the violin, while removing her brain tumour. What was that like?

Even to get that publicised was completely fortuitous. The night before surgery, one of my friends called me and said: 'What are you doing tomorrow?' I said: 'I am removing a brain tumour from a patient whose tumour is near the motor area of the brain, and I'm going to do it while she is awake and playing the violin’. 

He said: 'That's pretty amazing’. It never occurred to me that anybody would be interested. He said: 'Get the patient's permission, and let the hospital communication department know. They might be interested in filming this’. I just said, 'Okay’. That was 8:00pm the night before. I managed to call the communication department, and they agreed to come out and film it. 

The patient was very happy to be filmed, and 3.5 billion views later, people are still paying attention to this story. If my friend had not made that phone call the night before, it would have been just another day in the office, and nobody would have been any wiser. 

We do a lot of awake surgery. I do awake surgery both in my tumour work, when I'm removing tumours from patients, but also when I'm doing my deep brain stimulation work, because the idea of having the patient awake is to be able to assess their function during the surgery. 

When I'm doing deep brain stimulation, for example, for tremor or rigidity in Parkinsonian patients, I want to see those symptoms improve on the table, so I know I'm in the right part of the brain.

When I'm doing neuro-oncological operations, removing tumours, if they are near those parts of the brain that have critical function, like speech, movements, vision, then you want to be able to map those parts of the brain, so you avoid damaging those parts when you are removing the tumours. We have become really good at this in the past few years. 

We can monitor lots of these functions with the patients asleep. Not speech, as yet, because when you sleep, speech is too complex. That's just not feasible properly, at the moment. For many motor functions we can monitor even when the patient's asleep. 

For example, we can safely do an operation with them asleep, monitoring the motor pathways to ensure that, for example, the patient doesn't become paralysed. We can make your fist, we can move your arms, we can move your legs without any problem. 

What we can't do is map those highest functions of the motor circuits when the patient is asleep. It's one thing being able to move your arm, or make a fist, or hold a cup, which we can easily monitor when the patient is asleep. 

It's another thing to be able to continue your work as a concert violinist, moving between one string to the other, while controlling all the pressures, to the professional extent of musicians. For that, you have to have the patient awake, because that is highly intricate. That's one step ahead of what we've been doing so far.

This particular patient was a semi-professional violinist playing in various orchestras, and for her, being able to preserve that function was crucial. Around eight years ago, before she presented to us, she presented to another neurosurgical unit in her locality. (She's not from our local hospital. She sought me out.) 

She had this very large tumour near the motor part of her brain, and was only offered a biopsy by her local hospital, because it was deemed too risky to remove the tumour. From the biopsy, she had radiotherapy, chemotherapy, and that was fine, because it kept the tumour at bay for about eight years - until the tumour started growing and also showed some evidence of becoming more aggressive on the imaging. 

At that point, she sought me out, and was guided to me by one of the tumour charities.

I'm also slightly musical myself. I play the piano. I also did a degree in music, alongside my medical degree, many years ago. She felt that I could understand her desire to have her violin playing ability preserved, because for her, she would rather not survive if she couldn't play the violin. 

For her, that was the centre point of her quality of life, and she felt that if she said that to a surgeon who had no appreciation of music, they would potentially not take her seriously, because: 'So you're going to lose your life, just because you want to play violin?' 

That may not make sense to somebody who hasn't got that kind of love for music. She knew with me, I would understand that, and would go the extra way to do that. It was quite challenging, because there were lots of aspects we had to think about before surgery. 

Even the positioning of her head during surgery, so she could play the violin without poking me and my assistant in the eye, standing behind her head, operating on her brain. There were lots of logistical things we had to think about, that we did. Her operation went very well. 

It's well over a year ago and she's still completely tumour-free. No recurrence of the tumour. She's doing very well, and  had her first concert three weeks after the operation. That was the proof that we managed to get the tumour out, and leave her back in.

 

What did winning The Brain Tumour Charity’s Clinician of the Year award in 2018 mean to you?

That was a massive privilege, and I did not expect it. When I had the phone call, it was quite moving. I've had many awards in my life, but most of them are from peers, which is great. It's lovely to be appreciated by your peers, and it's an honour. But when an award comes from the patients - patient groups, and charities - it brings a different angle. 

It's amazing to realise that what you do has such an impact on patients -  that they come to you, and appreciate you - so that was incredibly important for me. It is probably the most important award I've ever had, because of the contribution I had made to the life of patients with brain tumours. 

I spend about half my life thinking about brain tumour patients, operating on them, running the service, and the award recognised that, and I am eternally grateful. 

 

What are some of the biggest remaining challenges within neurosurgery?

If you look at every discipline within neurosurgery, it's all massive challenges, so let's start with brain tumours. We've got really good at operating on them. When I first started neurosurgery, or when I was a registrar, the average survival for a patient with malignant brain tumour was merely six months. 

Now we have many patients with two-and-a-half or three years, or even longer. We have really advanced quite a lot, but that's still hopeless.  We need a cure for brain tumours. We cannot just sit back, pat ourselves on the back and say: 'Fantastic. 

My patient's survival is five or six times better than it was when I first started.’ So what? This is nothing to be proud of. We need to cure brain tumours, so there's huge amounts of work left to do. 

We've got to understand the physiology, the anatomy, the pathology, every aspect of brain tumours a lot better, in order to develop novel and new treatments for them, because we're still nowhere. Three-year survival for a malignant brain tumour is still hopeless, so we need to do a lot better.

In the field of neuromodulation, my other area, we've done very well in understanding how neuromodulation can help patients with movement disorders, but there is a huge amount of potential for other disease categories. 

The biggest challenge to all health services are from neurodegenerative conditions - Alzheimer's disease, all those diseases that cause a lot of morbidity, and are also incredibly costly for society. I'm a great believer that neuromodulation can help those conditions to a great deal. 

Parkinson's disease is a neurodegenerative condition, and at least symptoms get so much better with neuromodulation, so surely we can translate that into other neurodegenerative conditions. We just need to understand them better, to identify targets better, to understand how we can deliver our neuromodulation in a more efficient way. All those things will happen, but there are still challenges. 

We're making slow progress, or maybe I'm just too impatient. Maybe things are progressing fast, but for me it's too slow. There are many other challenges in neurosurgery. We still have infection. We need to find a way that we can avoid all the risks from infection. 

Every time you open the skin, there is a small risk of infection happening, and in neurosurgical patients, an infection can be a disaster, because if the blood gets into the central nervous system, that can be very difficult. Surely there must be ways of nanotechnology, that we can potentially try to combat something as basic as an infection in our patients.

 

What makes a great surgeon?

What makes a great surgeon is being a great clinician in the first place. There's a tendency to think that surgeons are not doctors. But you have to be a doctor. If you're not a doctor, you're not going to be a surgeon. 

You need to have all those qualities that a doctor should have - so you need to have empathy, compassion, and to be able to put your patients first. Those qualities are absolutely critical, before you can even hold a knife to start surgery. 

First and foremost, you learn to become a doctor and then become a surgeon. Assuming that you've got all those qualities, then there are some specific ones for surgeons. In my own field, neurosurgery, there are a few qualities that are essential. From a technical point of view, you've got to have the stamina if you want to become a neurosurgeon. 

A five- or six-hour operation is average for a cranial neurosurgical procedure. Sometimes operations take ten hours, fifteen hours, twenty hours. You've got to have that ability to continue and keep your concentration, so it's absolutely critical to have stamina, because operations in neurosurgery can be long. 

Another good quality is vision. You've got to be able to see what you are doing. If you can't see, you can't cut safely. It seems simple, but it's crucial. We have lots of tools in neurosurgical theatre, like microscopes, that give you magnification and illumination to be able to see better. Then there’s manual dexterity - you have to have that. You have to have a certain personality. 

You've got to be very tenacious in neurosurgery, because our cases are not as straightforward. If, in neurosurgery, something goes wrong, it can go wrong pretty badly. You've got to have a personality that can cope with that, and that can analyse what has gone wrong, learn from it, make sure it doesn't happen again, but carry on. 

With every single patient in front of you, if you lose focus, you can potentially bring them to harm. You've got to be tenacious, you've got to believe in yourself, you've got to be able to learn from your mistakes, but at the same time, you have to be able to carry on. Interesting personalities, often, neurosurgeons.

 

What tips would you give to students and doctors interested in neurosurgery?

If you are interested in neurosurgery then go for it. I'm one of those people who thinks that if you really want something you can definitely get it. I have no doubt that it is achievable. On the same note, you've got to be able to understand that there are going to be compromises. 

You cannot have everything. You have to make a choice, and if neurosurgery is what matters to you, then you should go for it, but you've got to understand it's a very difficult subspecialty, or speciality to get into. 

It's physically, emotionally, and mentally very demanding on you, and you have to make sacrifices in order to make a good neurosurgeon. There are many hours of learning involved. It will definitely conflict with your social life, but if you're happy to make the sacrifices, then there is no reason why not.

You need to get involved early, so one thing I have noticed from those students who are interested in neurosurgery, is that they tend to become ‘groupies', if I can use that term. They tend to hang around in surgical theatres. They do projects. They chase us. 

From very early on, they start presenting at conferences, and get their names known, and then they get some exposure to speciality. Then, when they go for national selection, they can use those experiences to hopefully succeed. 

It's hugely worthwhile, and if you love it, definitely go for it. It's very rewarding. However, you've got to understand that this is heavy work, and will take a lot out of you, and you have to understand there are going to be compromises. If you're happy to make it, go for it.

 

How do you cope when things go wrong?

Like anything in life, part of it is who you are, and part of it is experience and learning. One way to do that is to be quite analytical when you enter a difficult situation. Try to understand what has gone wrong and, if you like, do an analysis of what could have been done differently that could have potentially avoided that issue. 

You have also got to understand that everybody is prone to error, and even if you don't make an error, things could still go wrong because of circumstances outside of your hands. For example, infection. No matter how fantastic you are in terms of washing your hands, and taking all the precautions, there is no surgeon who has never had an infection, so it's going to happen. 

You need to try to do a root cause analysis, and find out what could have been done differently, and then next time, try to modify your behaviour or the environment. When something goes wrong, you've got to be able to learn from this, modify your behaviour, and try to avoid it happening again.

 

How did you first become involved in research?

My first experience of research was doing my intercalated BSc in biochemistry. I enjoyed many months of working on chicken fat, trying to identify proteins on it that we could then use to target to produce leaner chickens. I didn't really follow that line of research after I left the department, so I don't know how far they got. 

We get very lean chickens nowadays, so that research must have succeeded at some point. The first exposure to clinical research happened when I was in my first clinical year, my third year in medical school in Cardiff, where I did a project looking at the survival of patients with brain tumours. 

Even as early as that, I was interested in neuro-oncology. I presented that research at quite a few places. Then for my elective in the fourth year, I went to Toronto, and did a neurosurgery elective there. That's where I did my first set of publications looking at photodynamic therapy, again, for brain tumours, which was quite in fashion then, especially in Canada. 

That got me interested in publications and encouraged my inquisitive mind to try to think about things in terms of how we can change things, or how we can do things better. That has really just continued throughout my career. So at every stage, from house officer onwards, I don't think I ever did a job where I didn't publish at least one or two papers. 

My record was my six months SHR neurosurgery job, where I published seven papers in that six months. Once you get interested, you just carry on. I remain interested in research and publications, trying to answer questions, and solve problems. I'm a neuroscientist -  we enjoy surgery. The neuroscientist in me wants to continue, explore. However, my field of research is not purely surgery. 

I've recently published a paper totally on epidemiology of COVID. I had seen some patterns that interested me, so thought I needed to explore this, and together with my registrars and SHOs, we looked at epidemiological data from six or so countries across the world, and produced some models for predicting the severity of the disease. Nothing neurosurgical, but an interesting question to answer, so we tried to answer it.

 

What are your current research interests?

I divide my current research interests into neuromodulation and oncology. I try to live a parallel life within those two fields. In terms of neuro-oncology, I have several lines of research. I look at patient level research all the way to cellular research, but one of my most active areas of research is immunotherapy for brain tumours. 

That is something that I've done for the last ten years - trying to develop vaccines, and run trials looking at the effect of immunotherapy for brain tumours. One reason why brain tumours are difficult to treat are the heterogeneity. We use the term glioblastomas, the most malignant type of brain tumour. 

No two glioblastomas in two different patients are exactly the same. If we look at them at the really genetic cellular molecular level, they are different. The situation is even worse than that. In the same patient, if you sample two different parts of the same tumour, they are genetically slightly different.

There is a degree of instability in the genetics of these kinds of tumours, which makes them difficult to treat, because they're so diverse, so different. It is best to have a truly personalised treatment for that patient who deals with their own tumour, and I know of no other system more intelligent than one's own immune system. 

Remember, the immune system has evolved over millions of years to be able to deal with all those different pathogens that the world throws at you. A few years from now, we will have a routine of antibodies against COVID, because we are used to producing antibodies. 

We are used to producing things against dangerous pathogens. Why not stimulate your own immune system to tackle your own tumour? The theory is perfect. I'm not sure if that's going to definitely translate into reality when we get our trial data out, but that's the hope. 

That's why I've spent the last ten to twelve years working on this. I have been involved in developing a treatment and a trial looking at a personalised vaccine. So, remove the patient's own tumour, get the proteins, combine those proteins with the patient's own white cells, inject them back into the patient, and try to stimulate the patient's own immune system against the tumour. That's on the oncology side, where I've been quite active. 

On the deep brain stimulation, neuromodulation side, I've been interested in multiple areas, from anatomy, to targeting, to physiology. One area I've been particularly interested in has been the way technology and society can interact together. 

Deep brain stimulation, functional neurosurgery is very technologically driven. Electrodes, batteries, all the time. I've been really interested in HARPIC perception and acceptance of new technology. If you don't pay attention to that, you could be spending all your money and effort producing all this fantastic technology that nobody's going to adopt.

There is a cultural context to technology - I've been interested in that, and published quite a few papers on patients' perceptions, expectations, and satisfaction with the technology available to them. What we saw wasn't what we expected. 

For example, there were some pieces of kit that you would have thought, from an engineering point of view, was going to be acceptable to all patients, because it was fabulous. Not everybody wants that. And there are other factors that come into play that engineers may not necessarily appreciate. You need a clinician to bring those highlights. 

My line of research is really diverse. I don't believe in boundaries between disciplines, so I cover everything, because I enjoy everything.

 

Can you give an update from your current trials about vaccines to treat brain cancer?

We haven't got the final data of the study available yet, but we published our interim data in 2018/19, which is the most recent published paper. The trial design was interesting. It was a blinded placebo-controlled trial, which is what good science should be, because there is always going to be an element of bias if you don't control. 

As a chief investigator, even to date, I still don't know who had the vaccine and who had the placebo, but we did interim analysis looking at the whole patient population, without breaking that blindness. Nonetheless, what we saw was that we had about 30% of the patients who were living substantially longer than what we expected - seven to eight years. 

The best results we have seen clinically is about two-and-a-half to three years for glioblastoma patients, so to have a third of your study group living over seven years would be quite unusual. 

I cannot put my hand on my heart and say: 'Those were the people who had the vaccine’. They could have been just the ones who had the wonderful water, the placebo, but we don't know that. That's what science is. We have to wait until we can look at the unblinded data. But those interim data, for what they were worth, were really interesting. 

This gave me hope that when we have the final data available, then there'll be something to look forward to. For over a year now, we haven't been very active in terms of collecting all the final data, because of the restrictions with COVID. Hopefully, before long we will have access to that final set of data.

 

With Parkinson's and treatments, how important is collaboration between neurologists and neurosurgeons?

It's absolutely crucial. In fact, deep brain stimulation brought neurologists and neurosurgeons back together. In the old days, before my time, there was a close link between neurologists and neurosurgeons. 

They often worked very closely together, because there was no imaging, as such, so neurosurgeons were reliant on the fantastic clinical acumen of neurologists to localise the lesion for them. Which they would then do through a big open craniotomy, because they didn't have the wonderful MRI and neuronavigation to get you there. But at least neurologists could tell you roughly where the lesion was likely to be. 

Then your surgeon would operate and hopefully find the tumour and remove it, or find the lesion and remove it. Then, as much of the imaging happened, and as people continued to work on these artificial boundaries, neurologists and neurosurgeons followed their own separate routes. They are all part of the same neuroscience department, but unfortunately, our amount of interactions became less clear. 

Deep brain stimulation is one of those areas that brought the neurologists and neurosurgeons back together, for two reasons. First, the multidisciplinary team is crucial. Remember, this movement is all the patients in the 21st century - they are not neurosurgical patients. 

They are neurological patients, so neurosurgeons don't learn about the condition of Parkinson's disease, such as essential tremor, and dystonia. Those are conditions that neurologists learn about. So we need the neurologists and surgeons to screen the patients, assess them, and actually establish a diagnosis. 

As a neurosurgeon, I am not going to be able to differentiate Parkinson's disease from Parkinsonian, plus conditions like multi-system atrophy. It's not in my skill set. So neurologists are absolutely essential to identify and make the correct diagnosis, and therefore then present the patient. 

Our twice weekly multidisciplinary team meetings that we have for DBS involves the neurosurgeons and neurologists present. 

This deep brain stimulation created ‘interventional neurologists’, because when I do my awake surgery with a Parkinson's patient or tremor patient in theatre, neurologists actually come to the operating theatre. As I manoeuvre my electrode inside a patient's brain and seek the target, they clinically examine the patient and feed back to me in real time how close I am to the target. 

By evaluating the clinical condition of the patient, that is a form of guidance during surgery for me. They're actually in the theatre with us. They are not holding the knife, but they are in real time giving us feedback on the patient, and we really jointly do the surgery together. It's absolutely crucial. You can't do functional neurosurgery without an MDT, and this is not just the neurologists. 

In our MDT, neuropsychologists, and neuropsychiatrists are also absolutely key, because again, many of these patients may have cognitive impairment, albeit mild. They may have had a history of mood issues, and all those things need to be ironed out and diagnosed by the other MDT members, before it is safe for me to operate. 

Unless you have a good team, then chances are you're not going to have a very good outcome, because no matter how fantastically you cut, if you don't choose well, you're never going to get anybody well. 

Remember the basic motto: ‘Choose well, cut well, get well’. If you don't choose well, you can cut as well as you want, but nothing's going to happen, because you haven't done the first patient selection step properly.

 

What are your proudest achievements as a researcher?

Every time I’ve published something, it’s because I thought there was a need. It's like asking your parents which one of your children you like most, so it's hard to say. 

The interim paper we published on the results of the vaccine was an interesting one. I published a paper in Nature Reviews a few years ago, looking at the mechanism of deep brain stimulation. That has a very high impact, because even though we use this technique routinely, on a weekly basis, we still don't fully understand how it works. 

That paper, where we looked at various evidence and tried to speculate about the mechanism, has been very well quoted. I'm proud of that.  Equally, I'm proud of all the papers where, at the patient level, we have looked at the patient experience and patient satisfaction, both in oncology and functional neurosurgery, because I think those are incredibly important. 

Research needs to be translational, and one of the most important aspects of translation is acceptability and the clinical effect - how well that is spread within the clinic is just as important as the basic science. 

Clinical research, basic science research, cultural research, they are all equally important to me, and it's hard to pick individuals out of those.

 

What research question would you like to answer?

I want to be able to find out how we can help neurodegenerative conditions, because those are a massive burden, and because I'm on the functional neurosurgical side - it's something I deal with day in, day out. 

I've been quite active in trying to extend the usage of neuromodulation techniques to neurodegenerative conditions. We've got a few projects coming up looking at the use of deep brain stimulation outside movement disorder, which could be interesting. 

On the oncology side, immunotherapy is going to be the key. Equally, we are working on developing new techniques to make surgery safer and better, to improve the extent of resection by improving the visualisation during surgery. Increasing safety, by improving the way we can monitor brain function. 

Those are hugely important, but in the long term, surgery is not going to cure brain tumours, because infiltrating brain tumours, glioblastomas, are not a focal entity. What we see as a mass is just the tip of the iceberg. What we need to do is to deal with all those tiny, microscopic cells which are already spreading well within the brain, even before we can see the mass as a discrete structure. 

To deal with that, we need something which is personalised, and  specific to the patient, and immunotherapy is what's going to eventually, hopefully, deal with the underlying problem. Until then, we still have to deal with the mass, because removing the mass itself is hugely important. 

They will see some improvement with the quality of life, and the length of life, but it's not going to be the fundamental answer to tumours. We need to look elsewhere. I hate sticking to boundaries. I'm a surgeon, but I spend lots of my time doing immunotherapy stuff, which has nothing to do with surgery. 

 

What lessons have you learned?

My motive in life is that I start every single day with a completely blank sheet. I never feel proud of what I achieved the day before, because for me, the day before didn't matter. The day before has already finished. I start every morning with zero achievements - zero to be proud of. 

I haven't done anything. It's just a brand-new day, and I try to make that one day matter. When I finish the day, and eventually go to bed, at 2:00am or 3:00am, I want to have achieved something that day. If I have achieved something, I'm happy. If I haven't achieved, then I am not so happy, and I have to think about how I can change that. 

When I wake up the next morning, even if I had ten prizes, or twenty publications, or helped a thousand people the day before, it doesn't matter. I start with a blank sheet, and I want to make that single day count. If you become proud of what you achieved yesterday, you're never going to build it tomorrow. 

I've seen it across societies, cultures, thousands of years of history - those people who make tomorrow matter are the ones who work for it today, not because their ancestors 5000 years ago did something really good. 

So they can be proud of that. It's great to know the history, it's fantastic to learn from it, but don't feel so proud of it that it stops you from being motivated, because: 'I've done it all now, why should I bother?' That's not going to get you anywhere. 

This is a very important lesson - never be proud of what you did yesterday. Just learn from it, and try to be proud of what you're doing today. 

 

Are there any habits that have helped?

I'm incredibly organised. They say if you want to get something done, give it to a busy person, because  the reason they can be busy and efficient is because they're organised. If you're not organised, it's going to be very difficult to multitask. 

I'm multitasking 24/7. I'm completely obsessed.  If I don't find other people around me organised, it can be slightly irritating. Organisation is very important if you want to succeed. You need to be able to arrange your time to make capacity for what you need to do.

 

Have there been any people who you've looked up to?

In terms of my career role models, one of the earlier ones was back in medical school, the professor of neurology, Mark Wiles. He was fantastic, because as a second- or third-year medical student, I had become a bit of a groupie. At that point, I hadn't quite decided what I wanted to do. 

I knew I wanted to do neuro, because I loved to understand how the brain works. But I had no idea I was going to do neurology, neurosurgery, neuropathology. I talked to Mark, and he greeted me with open arms. I was a second-year or third-year medical student. 

He didn't have to be so nice to me, but he was very kind. He allowed me to just tag along with his firm. I spent hours with Mark. He introduced me to the neurosurgical department, so I did a project on brain tumours with the neurosurgeons, but through Mark. 

He even arranged my elective in Canada - he said to me: 'You've done neurology. Go and do some neurosurgery, and then you can make your mind up’. He put me in touch with Professor Thomas, who was another great role model. He was a professor of neurosurgery at Queen Square. 

A great man, very understated, and not really appreciated, primarily for medical political reasons. He was a very nice guy. Again, I was from Cardiff, he was from London. I was introduced to him by his colleague, but nonetheless, took the trouble of arranging my elective in Canada for me. 

That was during my medical school years. Later on, my neurosurgical role model has got to be Professor Alim Louis Benabid, the man who invented the modern deep brain stimulation, professor of neurosurgery in France, Grenoble. I spent a year with him. 

I learnt a huge amount from him. He's not only the brightest man I know, he has won everything except the Nobel Prize - and he should win it. Not only a lovely guy, but also just a really nice human being. 

That's Professor Benabid, god of neurosurgery. You call him one night, and say:  'Prof, where are you?' He says: 'I'm looking after my grandkids'. So that's great at every level. He was fantastic. That's my professional role models.

My personal role model is my mum, because she is so intelligent - equivalent to Professor Benabid, I guess! She's incredibly able. In order of magnitude, more able than I am. And she's very bright, and even more organised than I am. She's a fantastic role model.

 

How did you become interested in music? And how do you maintain a work-life balance?

I've always loved music. I also love dancing. It’s one of my biggest hobbies. I used to teach dancing. I don't sing, but I do dance, and play piano. I've been playing the piano and keyboard since I was a child. Then, when I was wanting to apply to university I was trying to decide what I should do. 

I loved medicine, but I also loved music. I thought if I did music at university, then I couldn't do medicine on the side. So I did medicine at university.  But I also enrolled with Open University to do my music degree, alongside medicine. 

I had my keyboard in my room at medical school. All my friends from my year, including the people living in halls, knew about my keyboard. We had this charity function at the medical school in Cardiff, called ‘Anaphylaxis’.  I think I played more for that than anybody else in the history of Cardiff. 

Every year, it was normally run by the third or fourth year medical students. But because people knew I played the keyboard, I played the music for it for four years in a row. Every year I was a fixed keyboard player for this. Then I did neurosurgery, which does take all your life.

Even though I have a piano at home, I'm rarely at home, so I don't play it so much. I haven't really progressed the last ten or fifteen years. I'm as good as I was ten or fifteen years ago, but certainly since I've been a consultant, around eighteen years ago, I haven't really had much time to improve my piano playing. Although I haven't lost it - I'm at the same level.

Where I do play quite a lot is during conferences. The whole of the neurosurgical community of the world knows I play, so every time after a conference, in a hotel, or restaurant, or bar somewhere, I'm always on the piano.  

And when I get the chance, I still dance quite a lot. In terms of work-life balance, I haven't really got that, because I don't look at my work as my work at all. I love to understand how the brain works, and to work with patients, so that is my life. I don't see that as work. 

Again, there is no boundary. I don't do boundaries. I don't set my work. It's just one complete thing. I'm at work at around 7:00am, doing clinical work, operating, and seeing patients. Then I finish at around 7pm. When I come home, I start writing my papers, or doing my research until around 1:00am, and then I sleep, and wake up, and continue, and it just carries on. 

I don't see that I have to have protected home time. It doesn't work like that. I guess there are people out there who look at medicine as a job. I don't see it as a job. It is just who I am, so I live it. I don't do medicine, I live medicine.

 

What's your favourite book?

I read quite a lot of books, but have a very short attention span, which goes with my personality of trying to do a thousand things at the same time. It is quite difficult for me to fix on a single book, and just keep the interest at that level for 400 pages. 

What I really enjoy are magazines, because you get a new one all the time, so the variety keeps me going. I've been a member of National Geographic Society since I was a kid, and read every single issue. As soon as it comes through the door, I read it cover to cover, because it's diverse, it's interesting, and it’s fascinating to learn about so many different things. It fits with my short attention span.

Even when I was a kid in Iran, there was a very similar Iranian fortnightly magazine called ‘Danesh’, which means ‘the knowledge’. Since the age of nine, I was always there at the magazine shop, the first day and the fourteenth day of the month, to buy the first issue. I used to memorise it word by word.I don't do that with National Geographic anymore - I'm a bit busier now. 

But when I was a kid, I used to memorise the entire magazine word by word, every two weeks. I knew the whole thing, like an encyclopaedia. That was similar to National Geographic, although it was a bit more diverse and a slightly lower level for children as opposed to adults. I've always been like that. I get hooked on a magazine and just devour it. 

 

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.