AFP Cambridge Flashcards
Why the AFP?
- Introduction - My aim is to become a leading academic neurosurgeon. And I believe that achieving that involves not only clinical excellence but also excellence in research. Hence, my main reason for applying to the research AFP at Cambridge is to build and improve the wet and dry lab skills necessary for neuroscientific research, both of which in combination will allow me to tackle unsolved problems in neurosciences; whilst also developing my clinical inductive and deductive reasoning skills to become a great clinician to my patients. And I believe Cambridge is the perfect place to achieve that.
- Research:
In terms of research, my main focus of research at the moment is cervical myelopathy. It is an extremely debilitating disease, which is unfortunately managed inadequately in the UK, mainly due to plenty of unanswered questions on how to manage it best. I am currently running two cohort studies as research lead at Imperial, building machine learning algorithm that will allow earlier diagnosis and treatment outcome predictions. As research fellow at CNOC at Harvard Medical School, I am looking at how low Frequency ultrasound can fast track early non surgical treatment in patients unlikely to reposed to spine surgery. And in 2022, I will look as hon research fellow at university of Oxford how functional neurosurgery can change the autonomic dysfunction in myelopathic disorders. I aim to continue and expand the research skills I have and will learn in this institution at Cambridge. Why Cambdrige? Because the most powerful and important research on cervical myelopathy done in the entire world is done in Cambridge, by Prof. Mark Kotter, consultant academic neurosurgeon and researcher working at MRC Stem Cell Institute. His work is the reason I got interested in cervical myelopathy in the first place, and I believe his stem cell approach to spine injury will create a huge leap in cervical myelopathy management, and I want to give my all in helping him reach this. I have already reached out to him and spoken to him he has expressed that he is very happy to supervise me for my research proposal, in which aim to use machine learning to unravel novel methods of how to employ stem cells to treat permanent cervical myelopathic spinal cord damage. Ultimately, my plan is to complete the AFP in Cambrige, and then strive towards completion of an ACF and subsequently, a PhD in functional neurosurgery at University of Cambridge. - Clinical - Clinically, the top notch clinical education with its world class reputation and training at Addenbrokes Hospital is unparalleled. It would be an outstanding opportunity to train among leaders (national and international) of medicine and surgery so I can try become half-as-good as clinicians as they are, which in my eyes would already be a great outcome. Also DGH Hospital plus tertiary Center which is a very well rounded clinical learning experience; and being on Europe’s largest biomedical Center means that I would have much more ways and people to collaborate with and learn from them how to be a good clinician scientist.
- Personal - I love cambridge as a city, it consists of a community of very friendly, vibrant and enthusiastic people who I would love to live among. Also, the nature, rivers and valleys in Cambrige and surrounding East Anglia country side are a lovely way to gain relxation from work.
What is your single best clinical or research achievement (paper/presentation/or prize) and why?
My best research achievement is the publication of the paper “Clinical predictors of shunt response in the management of idiopathic normal pressure hydrocephalus (iNPH)”, where I am the first author.
During neurosurgical electives at Charité University Hospital Berlin and Imperial College London, I observed that in both world-leading institutions all patients with suspected iNPH received CSF shunt surgery. It confused me greatly that this invasive procedure was being used to diagnose iNPH. My confusion turned into frustration when talking to patients months post-operatively, as many suffered from surgical complications, without experiencing any clinical improvement.
Hence, I performed a literature review to find answers on evidence-based guidelines to predict shunt responsiveness, without success. When embarking to answer this question myself, I was told by neurosurgeons that it would exceed my ability as a medical student to perform a robust meta-analysis due to the vast quantity of data. To make matters worse, halfway through the full-text literature search, my supervisor, who had promised to recruit statisticians, left the project.
Despite these challenges, I persevered. I lead my research team through >7000 papers, taught myself how to compute a multivariate meta-analysis using R programming and wrote the manuscript without supervision. The efforts of my team and I lead to our work being published in the European Journal of Neurosurgery. It is so far my greatest achievement, as we provided robust evidence on clinical predictors of shunt response, which will hopefully spare future iNPH patients from unnecessary shunting, thereby improving their quality of life.
Give one example of a non-academic achievement and its significance to your application for a special experience programme.
On April 21st of 2019, Colombo - Sri Lanka’s capital and my birthplace - fell victim to terrorist suicide bombings, killing a total of 267 people and permanently changing the lives of thousands. Having won the Blythe Art Award from Imperial College London, and having displayed my paintings in two exhibitions, I opted for art as a means to raise money. However, I realised that this venture would be difficult to conduct on my own.
Hence, I founded a charity organisation, consisting of 20 members of different beliefs and professions. Together with art students from the Royal College of Art, I designed a T-shirt remembering the victims, photographed it on models, and advertised it with marketing students through social media. We managed to raise over £500 for families of victims in the first week.
Adapting to this unfamiliar environment was a difficult task; I had to learn quickly about supply chain management and marketing, adapt to a completely different application of arts onto fashion, and work effectively in a large team. In the specialised foundation programme, I will face situations where I will have to adapt to novel challenges and opportunities quickly. I anticipate that this will involve switching between different roles, from lab scientist to data scientist to clinician. To retain excellence in each one of these domains, I will require to employ multi-tasking and time management skills. I aim to utilise the experiences and skills gained through my charity work to tackle the challenges of an academic career.
Why Research AFP?
I believe that becoming a successful academic neurosurgeon involves not only clinical excellence but also advanced expertise in research. My main reason for applying to a research SFP is to build the wet and dry lab skills necessary for neuroscientific research, whilst also developing my inductive and deductive reasoning, both of which in combination will allow me to tackle unsolved problems in neuroscience.
Working as Bioinformatician in the Brain Cancer Metabolism Group at the German Cancer Research Center, supervised by Dr. Christiane Opitz, empowered me to use R programming to analyse biomedical data. I have then expanded these skills in meta-analyses and two registered, sponsored and ethics approved cohort studies as research lead at Imperial College NHS Healthcare Trust using machine learning for early diagnosis and treatment prediction in cervical myelopathy patients. In my SFP, I intend to expand this knowledge and focus on the application of machine learning in the early diagnosis of cervical myelopathy, as well as the use of novel stem cell therapy for cervical myelopathy and spinal cord injuries. For this research I have already found a supervisor in Prof. Dr. Mark Kotter from the MRC Cambridge Department of Stem Cell Institute and Department of Neurosurgery, who I talked to and they are very happy to supervise me.
Fortunately, I was appointed as Honorary Research Fellow from April 2022 at the University of Oxford - Nuffield Department of Neurosciences, where I will aid research on the using functional neurosurgery for chronic pain, including in cervical myelopathy, through experimental and statistical work, supervised by Professor Alexander Green. My aim is to improve my neuroscientific research skills during this fellowship, and I seek to continue to expand and improve them by choosing Prof. Mark Kotter’s lab for my AFP, to produce high-quality research that will improve patient outcomes. Ultimately, my goal is to pursue a ACF after the AFP, and finally complete a PhD in Neurosurgery, ideally under Prof. Mark Kotter.
Please outline your previous research experience and achievements.
My most recent experience involves an ambispective cohort study, which aims to create a machine learning (ML) tool for the early diagnosis of cervical myelopathy (CM) and treatment outcomes prediction. After studying ML programming as an auto-didactic learner, I have taken this ongoing project from conception to pilot study, including writing the research proposal, securing sponsorship from Imperial College London, gaining ethics approval, and starting data collection. Moreover, I have published a meta-analysis on clinical predictors of shunt response in iNPH in the European Journal of Neurosurgery and have presented the findings at three international conferences, in Europe and the US. I am currently writing two further meta-analyses on radiological and biochemical predictors to finally publish clinical guidelines on iNPH diagnosis. Furthermore, I have studied psychological safety in primary care teams, and the effects of primary care spending on unnecessary A&E attendances, and have presented both at RCGP Annual Conference 2021, and published in BMC Health Services and Annals of Internal Medicine. I have worked as Bioinformatician at the German Cancer Research Center, building pipelines for multiple gene expression in brain cancer metabolism, under Dr. Christiane Opitz. Furthermore, I have worked as Research Intern in the Leibniz-Institute of Analytical Sciences, investigating the proteomics of human platelets using PCR and HPLC. Finally, I have been awarded the SBNS Undergraduate Award to support my confirmed honorary research fellowship at the University Oxford - Nuffield Department of Neurosciences from April 2022, under Professor Alexander Green, researching functional neurosurgery and the autonomic nervous system.
Academic medicine requires an individual to work successfully in a team. Describe a time that is relevant to your foundation training when you have worked as a successful member of a team and identify your role and contribution to this success. Explain the significance of this experience to your application.
During my BSc in Management at Imperial College Business School, I investigated barriers and facilitators of psychological safety (PS) in primary care teams (PCTs) with six fellow students. We aimed to write a systematic literature review (SLR) on this topic and conduct a qualitative study involving different members of NHS PCTs. Having experience with bioinformatics, I offered to work on the SLR. Working closely together with my sub-team, I taught them how to perform a meta-analysis, and learned from them how to systematically screen the literature. This exchange of knowledge was based on a culture of flat hierarchies, mutual respect, and open communication. Working collaboratively, we finished the SLR early and submitted it to conferences and for journal publication.
Unfortunately, due to the COVID-19 crisis, access to GPs was severely limited, and the other sub-team was struggling with the qualitative study. I realised that their strength lied in qualitative synthesis rather than data collection, and having performed research focus groups before, I offered to interview all remaining 20 GPs, so the others could focus on their coding of the audio data. By doing so, we were able to finish our qualitative research study in time and won the prize for the best final project.
Scenarios in which challenges are too difficult to be dealt with by an individual are bound to happen during academic and clinical work in the foundation training, but I believe that utilising effective teamwork and synergistic working will enable my research team to overcome these obstacles.
What steps would you take to optimise the benefit of a special experience foundation post from the start of your training? What challenges do you foresee with working both clinically and academically?
I have planned the entire path way to starting my own study, while assisting in senior research at the University of Cambrige. accepted to the SFP in 2021. For the research block in AFP, I have already found a supervisor in Prof. Mark Kotter, academic neurosurgeons and researcher working at MRC Cambridge Stem Cell Institute and Dr. Benjamin Davies, both working on stem cell use in spinal cord injury, particularly in my field of interest, cervical myelopathy. I have spoken to them, and they have expressed that they are very happy to supervise me in my aim to use machine learning to unravel novel methods of diagnosing cervical myelopathy earlier and aid in their stem cell research in for spinal cord pathologies. I would immediately contact the AFP neuroscience lead Dr. Chan to get his approval for their supervision.
I have already written a complete research proposal in which I included wider stakeholders such as patients and consultant neurosurgeons for the research design process to make it more relevant and ethical, which has been peer reviewed and once accepted to Cambridge AFP in January, I will convert it to Cambridge format and send it to Prof. Mark Kotter for his review and guidance. Once, that is complete I will get in touch with Cambridge Research Committee to aid in my IRAS application and sponsorship queries, and would apply for funding. If everything goes to plan, I will have NHS REC approval by August. Simultaneously, I would also reach out to keen specialised foundation doctors, academic clinicians and scientists to build a strong and collaborative research team. This early preparation would facilitate the actual start of the research study during my research block and would increase the likelihood of successful completion and publication of my research findings.
I am aware that my participation in the SFP would mean that I would have one clinical rotation less, which may negatively affect my acquisition of clinical skills. To counteract this, I would make sure that when on clinical rotations, I maximise my clinical learning. I would dedicate myself to working efficiently and effectively, and aim to attend both additional teaching as well as conducting self-study to consolidate my clinical skills outside of the ward environment.
Working academically and clinically will be difficult at times but I aim to overcome these challenges using efficient time management and working closely within my teams. Ultimately, working both fronts might be mentally and physically exhausting, and hence I plan to avoid burn-out by doing yoga and running through the beautiful countryside of Cambridge and East Anglia, as well as retaining a supportive social network.
Why Cambridge?
- Introduction - My aim is to become a leading academic neurosurgeon. And I believe that achieving that involves not only clinical excellence but also excellence in research. Hence, my main reason for applying to the research AFP at Cambridge is to build and improve the wet and dry lab skills necessary for neuroscientific research, both of which in combination will allow me to tackle unsolved problems in neurosciences; whilst also developing my clinical inductive and deductive reasoning skills to become a great clinician to my patients. And I believe Cambridge is the perfect place to achieve that.
- Research:
In terms of research, I am fascinated by functional neurosurgery and cervical myelopathy, and firmly believe that further research in this area in conjunction will reveal findings that will create a paradigm shift within neurosurgery, and medicine itself. I have done work on cervical myelopathy at Imperial College London as research lead of a prospective and retrospective cohort study, gaining full sponsorship and ethics approval, and started a pilot study. The aim is to achieve an early diagnosis and treatment prediction machine learning algorithm that will transform how healthcare practitioners manage cervical myelopathy. This research lead to me being accepted as research fellow of the computational neurosurgical outcomes team at Harvard Medical School, where I am currently working on the use of LIFUS in functional neurosurgery. Furthermore, for 2022, I have been awarded an honorary fellowship with Prof Green at Nuffield Deparment of neurosciences in Oxford supported by the Society of British Neurosurgeons to learn how to use functional neurosurgery for chronic pain including in cervical myelopathy - My aim is to help alleviate suffering and create a paradigm in this field - and the most powerful and important research on cervical myelopathy is done in Cambridge, by Prof. Mark Kotter, consultant academic neurosurgeon and researcher working at MRC Stem Cell Institute. I would like to continue my current work and learning curve by doing the AFP in Cambridge under Proef. Mark Kotter. I have already reached out to him and spoken to him and Dr. Benjamin Davies, whose paper sparked my interest in cervical myelopathy in the first place, and they have expressed that they are very happy to supervise me for my research proposal, in which aim to use machine learning to unravel novel methods of how to employ stem cells to treat permanent cervical myelopathic spinal cord damage. Ultimately, my plan is to complete the AFP in Cambrige, and then strive towards completion of an ACF and subsequently, a PhD in functional neurosurgery at University of Cambridge. - Clinical - Clinically, the top notch clinical education with its world class reputation and training at Addenbrokes Hospital is unparalleled. It would be an outstanding opportunity to train among leaders (national and international) of medicine and surgery so I can try become half-as-good as clinicians as they are, which in my eyes would already be a great outcome.
- Personal - I love cambridge as a city, it consists of a community of very friendly, vibrant and enthusiastic people who I would love to live among. Also, the nature, rivers and valleys in Cambrige and surrounding East Anglia country side are a lovely way to gain relxation from work.
- Conclusion - I think the University of Cambridge is the best place in the world to be a clinician-scientist, and to be able to work in such a stimulating and nourishing research and clinical environment, consisting of a multiprofessional network who work symbiotically to push medicine forward, would be a great privilege.
What do you do outside of medicine?
Art - I love painting - particularly abstract painting, oil on canvas - love going to art galleries and exploring new artists - gives me great relaxation from work
Rowing - rowing allows me to destress and build endurance I need for my work, in the hospital and researcher
Travelling - allows me to learn new languages (I love learning new languages) and explore new cultures
Coding - I love solving problems - learning new programming languages (favourites are python and R) - especially deep neural networks are something I auto didactedly teach myself in the free time - love solving complex challanges (hence also love chess)
Should patients be involved in research?
Yes
-Research teams which involve patients and the public run better studies because:
- they are more relevant to participant
- they are designed in a way which is acceptable to participants
- they have participant information which is understandable to participants
- they provide a better experience of research
they have better communication of results to participants at the end of the study.
Example cervical myelopathy study:
- relevant: included patients with cervical myelopathy , neurosurgeons, physiotherapists and GPs early on in our study design because they are the two target populations of our research and can give valuable insights and corrections - they are eager to help in an endeavour that might help themselves and others in the future
- acceptable to patients: we found out that our first questionnaire and examination was too long in our pilot study from the patients POV - hence we shortened it - also some tests were to uncomfortable for the patients so we removed them to ensure patient safety
- explaining the research study to patinets, most of the lay people, allowed us to establish gaps in our patient information sheet and made us simplify our proposal so all stakeholders can understand it
- it is simply more ethical to involvement them! - four pillars of ethics (beneficence - involving them improves research and patient safety; non-maleficence - by involving them you can identify and eliminate potential threats to their health arising from the study more effectively; autonomy and justice - they deserve to be involved in something that may affect them
Name a paper you recently read
Eide and Stanisic (2010) - “Cerebral microdialysis and intracranial pressure monitoring in patients with idiopathic normal-pressure hydrocephalus”
How I came across this paper:
- invited to write a letter to the editor on their paper by the European Journal of Neurosurgery
Study summary: Non-randomised - single center - prospective cohort study; investigated the use of intracranial pressure monitoring for prediction of shunt response and cam to conclusion that ICP wave amplitude can differentiate shunt responders from non-responders.
Relevance: High relevance! Current gold standard is shunting for diagnosis and treatment - associated with costs and complications + not all shunted patients benefit from it (benefit vs hazard, quite unethical actually) 0- hence the search for less invasive predictors of shunt response with high diagnostic accuracy is very important
P: Population was a sample of approx 40 patients (mixed age and gender) - referred from all over Norway
I: Intervention was ICPM and VP shunting.
C: No control
O: Primary outcome is response to shunting. Secondary outcome is sensitivity and specificity of ICP wave ampltiude to predict SR.
S: Statistical analysis using SPSS.
Sources of bias on internal validity:
P: - potential selection bias (only 40?); not clear which co-morbidities patients have (neurodegenerative diseases ie Alzheimers present similary to iNPH (mimics) and can be a huge confounder in this setting - not controlled for)
I: All received the same intervention - but reading of ie ICPM - if investigators new about the research aim then this can cause investigator and hot stuff bias - no BLINDING reported
C: No controls - hence very one sided research study - need controls for different treatment arm with ie different investigation like tap test to effectively compare
O: The used objective scales to record functional neurological recovery which is good. However, only quantitative - using a qualitative validated scoring tool would have been better because it would make the research more holistic (QUALY)
S: Did not do a power calculation - highly unlikely that the sample size is sufficient to give statistically highly valid result. Potential that data is skewed.
Conclusion: overall low internal validity due to several sources of uncontrolled bias in study designs- hence limited clinical significance.
External validity also likely low as small sample size and no details on comorbiditdy and ethincities etc
Interesting point: Huge conflict of interest - main author has financial interest in the company that manufactures ICPM recorders - they used them in the study!
Understanding the nature of dark matter is an example of an unanswered high priority challenge in astrophysics. Please give an example of an unanswered high priority challenge in medicine and explain the reasons for your choice.
I believe that the dark matter equivalent of medicine is the so-called “hard problem of consciousness”. To paraphrase cognitive neuroscientist David Chalmers (1996) who coined this term: What is the relationship between physical processes, such as neurophysiological mechanisms, and consciousness, particularly experience?
“Easy” problems, relatively speaking, as explained by cognitive psychologist Stephen Pinker, are problems that with sufficient time, funding and intelligence could be logically solved, as they can be reduced to a mechanism. However, even if we overcame the “easy” problem of completely elucidating neurobiology, we would, in theory, still not be able to answer the hard problem of consciousness. For example, a perfect replica of oneself, although identical functionally, would have a completely different experience; hence, experience cannot be physically explained. Thus, unlike the physical mechanisms of the brain, we cannot prove that consciousness is a sum of parts, and as it evades logical reduction, it remains an unsolved question in neuroscience and medicine. Like the dark matter problem in astrophysics, consciousness is elusive to our current understanding of neuroscience.
What exactly solving the hard problem of consciousness will bring to clinical medicine is difficult to hypothesise, but it may shine light onto some of the most important meta-cognitive questions such as the nature of psychogenic illnesses and the mind-body connection. Taking it further, the understanding of consciousness may empower medicine to overcome its current limitations of treating illness by revealing means of metaphysical healing – and may, in the process, completely alter our understanding of medicine itself.
