AFP Oxford Flashcards
Why the AFP?
- Introduction - My aim is to become a leading academic neurosurgeon. AFP would allow me to acquire skills for both.
- Research:
In particular, I am fascinated by functional neurosurgery, and firmly believe that further research in this area will reveal findings that will create a paradigm shift within neurosurgery, and medicine itself. Have done work on cervical myelopathy pain - fellowship with Prof Green at Nuffield Deparment of neurosciences - would like to continue this work in the AFP and then strive towards completion of an ACF and subsequently, a PhD in functional neurosurgery. - Research Continued
Ultimately, my main focus are patients, thats why i do medicine. I am strongly driven by improving patient outcomes; both in terms of mortality, as well as morbidity. Hence, I continuously seek to analyse and study neurosurgical practice to find ways to ameliorate patients’ lives. To work within the environment of a programme that nurtures and stimulates medical research, whilst also bringing it bench-to-bedside, is an opportunity I strive to utilise.
Lastly, having performed two cohort studies as research lead in the neurosurgical department of Imperial College NHS Healthcare Trust, I am aware of the financial demands of research, the difficulty of finding appropriate research supervisors and building a cohesive research team. the fellow AFPs and clinicans at Oxford would be invaluable supervisors and collaborates, the free choice of topic of research gives me a great deal of autonomy to focus on what I am most passionate about and the protected research break allows me to completely focus on research. - Clinical reasons - top notch clinical education and training at John Radcliffe hospital, would be a great opportunity to train among leaders (national and international) of medicine and surgery, extremely good reputation of hospitals in general in the Oxford deanery
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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. In my SFP, I intend to expand this knowledge and focus on the application of unsupervised machine learning using deep neural networks on big data, particularly the UK Biobank. My aim is to design novel algorithms to predict neurological disease accurately.
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 autonomic nervous system 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 capitalise on this opportunity by choosing a similar lab for my AFP, to produce high-quality research that will improve patient outcomes.
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?
Once accepted to the SFP in 2021, I would approach a research supervisor with similar research interests immediately, and then start working on a research proposal, involving wider stakeholders such as the general public and patients in the research design. I would then submit it for peer and sponsorship review from my SFP host unit, and apply for funding and IRAS ethics approval early-on. 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 painting regularly, as well as retaining a supportive social network.
Why Oxford?
Clinical reasons - top notch clinical education and training at John Radcliffe hospital, would be a great opportunity to train among leaders (national and international) of medicine and surgery, extremely good reputation of hospitals in general in the Oxford deanery
Academic Reasons - General: international academic reputation of univerity of oxford and associated institutions is unparalleled - to be able to work in such a stimulating and nourishing research environment, consisting of a multiprofessional network who work symbiotically, would be a great privilege.
Specific: The research I am interested in focussing in my career (functional neurosurgery) - the Nuffield department of Neurosciences are world leaders in - it would be a great opportunity to work side to side with world leaders in this field and learn from them and help them improve patient outcomes
Personal - I love oxford 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 Oxfords country side are a lovely way to gain relxation from work.
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 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!
