The journey only makes sense looking backwards.
Tomorrow is exactly twenty years since I started medical school. So, I thought it would be interesting to reflect on some of the key decision points that led to the position I’m in now.
One major caveat: this is all done with a heavy retrospective bias. An important anecdote I heard a while back is that ‘the journey only makes sense looking backwards’. That is another way of saying that we make up stories to explain the past and its consequences, rather than them having been truly causal.
With those caveats in mind, here are a few key decisions:
- Choosing medical school based on badminton team calibre
At the time when I applied to medical school, I played a lot of badminton, and I ranked the medical schools I would apply to based almost entirely on their badminton team’s performance. At the time, Bristol and Birmingham had very good badminton teams. I also applied to Cardiff, where I hoped that if I got in, there’d be the potential to train with the Welsh national team. I didn’t consider Oxbridge or London, predominantly based on their badminton team quality.
Birmingham was one of the top four universities in the whole country for badminton and the other three (Sheffield Hallam, Loughborough, and Bath, didn’t do medicine).
There were several reasons why this turned out to be an important decision. Firstly, with the view of my current career (paediatric hepatology) in mind, Birmingham is a liver transplant centre (adult + paediatric). In fact, in some years, it has been the busiest liver transplant unit in the whole of Europe. That led to me spending some time in the liver labs between my first and second years of university (during a summer when I stayed in Birmingham to play badminton), as well as being influenced by several amazing clinician scientists (including, but not limited to, David Adams). This is what eventually helped me decide that I wanted to do hepatology, and subsequently paediatric hepatology.
In addition, coming top in the year overall was helpful for academic jobs. I don’t know whether I would have performed as well on a different style degree. The teaching/exams at Birmingham seemed to suit me.
There is part of me that does wish I had at least applied to Oxford or Cambridge. I expect that had I gone to either, I probably would have ended up doing even more fundamental science, and been less likely to end up working in hepatology.
- Leaving Birmingham
At the end of medical school, I decided I did not want to stay in the West Midlands for my foundation years. This was based on two things: Firstly, I decided that change was good, and that it would be important to see somewhere else. Secondly, I’d had a reasonably dreadful penultimate year at medical school in terms of a long placement at a hospital some distance away, and I just wanted to get out.
I chose to apply to London and to West Yorkshire (Leeds) for the academic foundation programme (now known as the specialist foundation programme). One sub-decision within this was that I was very specific about the jobs I ranked in London, because by this point I had decided that I wanted to do paediatric hepatology (see Decision 3). So I only ranked jobs based at King’s London that included a paediatrics rotation, and even then I excluded some that had multiple surgery rotations. This meant that out of hundreds of potential jobs in London, I only ranked about thirty of them. I then proceeded to totally bomb the interview and wasn’t offered any jobs in London. In Leeds, I applied to the gastroenterology team and was offered a post.
I think the reason this was so influential is that I believe that experiencing different ways of doing things is healthy. It got me out of Birmingham, which added some breadth to my experience. This was heavily counterbalanced by the fact that it was one of many interruptions to the flow of my research / academic career, because there was obviously no follow up from anything I’d been doing in Birmingham to what I did in Leeds.
Leeds is a paediatric liver transplants centre too though I discovered that there was relatively little basic science liver research in Leeds. That meant I was unlikely, at least in the short term, to be planning to work there beyond foundation.
Leeds was also significant for the people I met. Firstly, and most importantly, I met my wife in Leeds. And everything that followed from that (including two wonderful children) would have happened if I hadn’t gone to Leeds.
On the more academic front, one of the most influential people I met is actually not someone I worked with or who supervised me. I can’t even remember how I came to know him in the first place, but a guy called Professor Sir Alex Markham, who has a highly decorated career and continues to be closely embedded in science policy. He gave me lots of advice, but the best advice I remember was that I should go to “the best place in the world to do my research”, and ultimately my PhD. Empahsis was on place. He really ground into me that its is all about the culture of the lab. This is what led me to apply to Cambridge for my PhD. I even decided that even if I didn’t get into an ACF in Cambridge, my plan was to go to the East of England (Cambridge) as a regular paediatrics trainee and then try to apply directly to a PhD programme from there.
- Picking paediatric hepatology very early on
This has been touched upon in previous points, but it is worth making a point of itself. I chose very, very early on (in my fourth of six years at medical school) that I wanted to do paediatric hepatology. I’d pretty much decided the year before that I thought the liver was the most interesting organ, and that I wanted to do something hepatobiliary or hepatology related. I then decided I didn’t really want to do surgery, and preferred medicine. I then decided I probably preferred small humans to big humans. And I then stubbornly stuck to that decision, and totally focused my energy on building my entire CV around entry into paediatric hepatology at ST5/6 level as a paediatric trainee.
The benefit of this was that it meant my CV was highly tailored, which increased the probability of me getting the job I wanted. (As it happens, the year I applied to paediatric hepatology, there was only one job in the whole country (Birmingham) which meant I didn’t have any decision about where I went.)
The downside of this decision is that I had absolutely enormous sunk costs. When my research could have taken me down a different clinical route or I entertained the idea of another clinical path I’d already put so much effort in, and convinced myself for so long that this was exactly what I wanted to do, that I stuck with it.
On the whole, I’m not sure whether this is a good thing or a bad thing. It is certainly unusual: most people tend to have greater flexibility in their career decision-making until a later point. When you speak to other paediatric trainees, most didn’t know exactly what they wanted to do with their lives when they were 22. And when I look back, I’m pretty sure I didn’t exactly know what I wanted to do at that stage either; but I told myself I did, and I ran with it.
- Embarking on research side quests
I’d always been involved in a variety of research projects ever since medical school. Something was always ticking over outside of the day job. When I did my PhD, I decided (I’m not sure why) to set up a whole series of ‘side projects’ working with medical students in Cambridge. This turned out to be (a) enormously stressful, and (b) one of the best decisions I’ve ever made.
I clearly bit off far more than I could chew, with several genetic analyses and an absolutely enormous animal model meta-analysis. These projects lasted way, way longer than I’d originally anticipated, and probably somewhat detracted from the quality and depth of what I actually did in my PhD (sorry David [my supervisor]). However, all things considered, they were definitely worthwhile, because it meant I came out of my PhD with a whole series of senior author papers that I felt very proud of, and that were published in good-quality journals like the Journal of Hepatology, Hepatology, and eLife.
My PhD itself was another piece of work I’m proud of, also published in a good-quality journal (eLife). My current reflection is that even if I’d done nothing else and focused a hundred percent on the lab work of my PhD, I don’t think that would have made the difference to get it into Nature or Cell Metabolism.
The alternative point is that I was constantly told, by more experienced and much better scientists than I, that I needed to focus and stop being distracted by these projects. I think this is one of those examples where, by luck and probably an element of sheer effort, I happened to have a good outcome despite not making the correct decision. This has become relevant because, down the line, I have continued to struggle with taking on too many things simultaneously, and it probably has detracted from my work. I’d argue that over the last three to five years there have been multiple times when I’ve had too many different things on the go across different topics, which led to me spreading myself too thin and reduced my probability of success. So whilst I happened to get lucky and have a good outcome at that stage, I don’t think that is uniformly true.
(If I were to come up with a justification for why there was such a difference between that time during my PhD and the last few years, it would be because I have had an enormous clinical workload over the last few years, whereas while doing my PhD I had essentially zero. I could still devote sixty-plus hours a week to research. If I had some projects that I spent ten hours on, I could still spend fifty hours on my PhD a week; that has not been the case during my paediatric hepatology training and consultant time.)
- Formalising collaboration
One decision I was encouraged to take, again by more experienced people than me, was to formalise an informal collaboration. Over the previous five years, I’d been doing some work with a group of paediatricians across Europe who were interested in steatotic liver disease (at the time called NAFLD). I was recommended (I think by Professor Matthias Zilbauer from Cambridge) to formalise this as an ESPGHAN working group / special interest group.
At the time, I was deeply sceptical, because I thought this would purely add admin, rules, and regulations to work we were already doing. How deeply wrong I was. Just giving it a degree of formalisation and credibility actually did change everything. It helped provide momentum. It meant we had a responsibility to actually do stuff. And ultimately it has led to multiple papers, grants, and guidelines, and a much more connected paediatric steatotic liver disease field across Europe. For me personally, it meant an enormous amount of leadership experience, and helped to set up new opportunities I would not have had access to otherwise.
The downside is that it was another distraction, and it certainly meant I felt very conflicted in my move from Cambridge to Birmingham. In Cambridge I was working on metabolism and insulin resistance (therefore closely related to steatotic liver disease), but not doing any paediatric hepatology. Then in Birmingham I wanted to learn immunology and fibrosis biology in the lab, but not necessarily to work on steatotic liver disease. Subsequently, I have decided to square this circle by studying the overlaps between rare fibroinflammatory paediatric liver diseases and steatotic liver disease, whilst internally trying to feed observations into translational / clinical studies of steatotic liver disease. Challenging.
- Working with One 2 One Medicine
In my final year of medical school I met a highly charismatic medical student called Grant Milne who had just set up a company called One 2 One Medicine. Together, we quickly persuaded each other to set up an enormous series of revision courses, which spiralled into one of my main side quests over the next decade of my life, which I’ll discuss in a separate blog. In short, it is again one of those decisions I considered to be absolutely excellent, but also profoundly stressful, and nearly destroyed me in the process.
One of the decision points that led to and facilitated this was agreeing to run some near-peer teaching revision sessions at the University of Birmingham. This ultimately meant I had done more than a hundred hours of lecturing before the end of medschool, and resources to teach most of preclinical medicine (in piecemeal at least), prior to meeting Grant. Had I not done all that near-peer teaching, there’s no way I would have had the idea to embark on such a journey with Grant.
A closing thought
It’s also important to reflect that I’ve focused here on professional / academic choices. These are not totally separate from my family / personal choices. No decision has been made totally in isolation, and there are other things I would consider doing, or not doing, if it weren’t for the joint decision-making with my wife. I’m not going to go into detail, as these are personal decisions, but I’m happy to talk about them at an individual level if people are interested.
Thanks for allowing me this self-indulgent reflection.
