- What is your job title and affiliation?
I am Visiting Professor in Clinical Biochemistry at the University of Oxford in the UK. I also work as an independent consultant in the field of diagnostics and healthcare.
- Briefly tell us about your educational and career background.
I obtained my first degree (Bachelor of Science, BSc Joint Honours in Chemistry and Physiology) from the University of London in 1967. I then took up a post as a clinical biochemist in Coventry; in this post I attended a Masters course in Clinical Biochemistry at the University of Birmingham. I continued my Masters research project in Birmingham to complete a PhD, which was awarded in 1972. I also completed my UK equivalent of Board certifications at that time.
In 1976 I moved to a post as Consultant Clinical Biochemist in Southampton in which I was responsible for part of the laboratory service, which included interpretation of results and advice on tests, working closely with clinical staff, and I was able to continue with my research. I moved to a similar position in Cambridge in 1980 – continuing in much the same role but being able to expand my research interests. In 1988 I was awarded the Chair of Clinical Biochemistry at the London Hospital Medical College – one of the oldest medical schools in the UK. In addition to being Professor of Clinical Biochemistry I was also head of the associated hospital laboratory. In 1996 I also took on the role of Director of Pathology for the hospital – head of all of the diagnostic laboratories.
In parallel with my hospital and academic roles I had been continuing to lead a research team with funds increasingly coming from commercial sources i.e. the diagnostic companies. I also became a member of a number of advisory boards including the Strategic Advisory Board of Bayer Diagnostics. In 2002, I joined Bayer as the Vice President of Outcomes Research with the remit to develop a strategy for building the evidence base for diagnostic tests, showing how test results can be used to improve health outcomes. At that time I was also offered a Visiting Chair in Oxford. I left Bayer at the end of 2005 and since then I have been working as an independent consultant working with new start up companies, and advising on outcomes research and the value of diagnostics.
- What are your Board certifications?
I completed my training and obtained my professional examination in 1972 – which at that time was the Mastership in Clinical Biochemistry (MCB), but is now equated to Membership of the Royal College of Pathologists (MRCPath). I should perhaps explain that in the UK there are two phases of training: basic and higher specialist. The first phase includes completing a Masters course, with in-service training in a recognised laboratory, and then the first part of the MRCPath examination. The second phase involves more in-service training and gaining additional experience, perhaps with some specialisation, as well as a research project, and then completing the second part of the MRCPath examination. You are then considered to be qualified to practice independently as a clinical biochemist (i.e. not under supervision) and you are effectively then fully accountable for all of your actions and decisions.
- With which professional societies/organizations (e.g. AACC) are you involved?
I am a member of the Association for Clinical Biochemistry (ACB) in the UK, the American Association for Clinical Chemistry (AACC) and the International Society of Clinical Enzymology. I am a Fellow of the Royal College of Pathologists, of the Royal Society of Chemistry and, of the National Academy of Clinical Biochemistry. I am a Past Chairman and a Past President of the ACB. I have also been the chair of the ACB’s Education Committee and led that committee in its development of the training programme in clinical biochemistry that is used today. I also chaired the Registration Council of Scientists in Healthcare when it was successful in achieving statutory registration for clinical scientists, making clinical scientists a regulated profession in the UK. I have been a member of the editorial board of the Annals of Clinical Biochemistry, and I am a member of the editorial board of Clinica Chimica Acta.
I have been a member of the Board of Directors of AACC, of the Board of Editors of Clinical Chemistry, of the Organizing Committee of the Oak Ridge meeting and, of the Nominations Committee, and I am currently a member of the Evidence-Based Medicine Committee. I was one of the vice chairs of the National Meetings Committee in 2004.
I was a member of the Scientific Division of the International Federation of Clinical Chemistry for six years. I was the Chairman of the Organizing Committee for the IFFC meeting in London in 1996.
I have also sat on a number of government committees advising on aspects of laboratory medicine. In particular, over the last two years, I have been the professional expert member of a team undertaking an independent review of pathology (laboratory medicine) services in England chaired by Lord Carter of Coles.
- Just for fun, tell us a few interesting facts about yourself:
I have been married to Ann for 39 years and we have two daughters, Carolyn and Emma. Emma is married to Daniel and they presented us with our first grandchild, Lucy Kate, in August of 2007. Having lived in cities for most of our working lives, in 2002 Ann and I moved to the Cotswolds, a rural area in the UK west of Oxford, so our pursuits are now more concerned with country life. One of my hobbies over the years has been walking, with some long walks completed with professional colleagues from across the UK. Thus, before the 1996 IFCC meeting in London, I organised a sponsored climb of the four highest peaks in the Lake District – to be completed in 36 hours. This exploit generated over $30,000 in donations and kick started a fund raising programme generating about $85,000 in total, which was used to provide bursaries for clinical chemists from other countries to attend the 1996 meeting! Although not undertaken as a sponsored walk, a smaller group of us undertook the Lyke Wake Walk, a historic funeral route to the cost in Yorkshire, 42 miles in distance which should be completed in less than 24 hours; we took just under 16 hours – which included three meal stops! When the 2005 IFCC meeting in Orlando was announced, Professor Nader Rifai and I were members of the AACC Board of Directors and thinking to repeat the fund raising activity of 1996, we hatched a plan to get the members of the Board of Directors and the IFCC Executive Committee members (who were meeting together in Florida) to sponsor us in a parascending “flight”. We raised $16,000 in 30 minutes for bursaries in 2005!!
- What area(s) do you specialize in?
I separate my interests into basic and analytical science, into clinical, and then into leadership and management. Thus I am interested in the mechanisms of disease, and in the mechanisms for modification of protein structure – and their application will be evident later.
My early training was under the guidance of an analytical chemist, Dick Richardson, and he taught me the rigors of analytical science. However my development of new methods came about through opportunity and need; opportunity when I met up with some microbiologists who studied novel bacteria and need when it was obvious a new method for acetaminophen was needed. The path this thinking took will be evident in the next section. My PhD supervisor, Herbert Sammons, had more clinical interests and he encouraged me to attend ward rounds on a regular basis.
When I attained more senior positions I became accountable for the actions of a team rather than for my own actions, and in so doing had to justify, from time to time, the resources committed to the provision of the laboratory service. I learned about Evidence-Based Medicine and its application in laboratory medicine. I will leave it to the next section to see how this all evolved to what I do today!
- What initiated your interest in this (these) area(s) and how did you eventually choose this (these) area(s) for your career?
The research for my PhD involved the characterisation of alkaline phosphatase in human bile, and an explanation for the changes in serum alkaline phosphatase seen in liver disease. In later years I attempted to raise monoclonal antibodies to alkaline phosphatase isoenzymes. I retained an interest in enzymes for many years and worked with some microbiologists on enzymes from bacteria surviving in hostile environments (e.g. extreme temperatures and toxic substrates). This work generated the first enzymatic assays for acetaminophen, as well as assays for salicylate, creatinine, and phenylalanine. My research group then went on to make a dipstick test strip with three pads that would detect acetaminophen, salicylate and alcohol in a single blood spot. Latterly working with novel enzymes and monoclonal antibodies sparked an interest in how to manipulate protein structure to change specificity.
In parallel with the development of new analytical methods – which often brought in the research funding (!) – I always had an interest in the clinical aspects of my job, both from the perspectives of understanding the pathophysiology of a disease and the mechanisms responsible for change in marker levels, but increasingly from the perspective of understanding why doctors request tests. It may be helpful here to point out that, in the UK, the clinical biochemist is trained to help doctors select the right tests as well as interpreting the results when needed; this role can also include advising on additional tests that might be of value, as well as rejecting requests for inappropriate tests. This part of my training has really come to the fore in more recent years, and it became clear that the evidence of the utility, or effectiveness, of many laboratory tests is poor. Cystatin C is a good example; my research was able to show that it is a better indicator of glomerular filtration rate than creatinine – but, it is a more expensive test. Therefore in order to use the test routinely you need to be able to show what benefit the new test will bring – basic, but it focuses the mind!! Around this time I was introduced to the principles of Evidence-Based Medicine by David Sackett, whilst he was working in Oxford, and he opened up a new way of thinking for me – shifting the emphasis away from looking at the relationship between the test result and the presence (and the severity) of the disease, toward understanding how the test result might help the doctor make a decision – and bring benefit to the patient. This way of thinking also helped me to open up the discussion on point-of-care testing – which had become bogged down in the discussion of technical performance and cost-per-test.
- What are your clinical and research interests?
Today they are firmly grounded in evidence-based laboratory medicine and outcomes research, and in point-of-care testing. This gives a real opportunity to explore the impact of laboratory medicine on improving health outcomes – and the challenges that involves. This brings me into contact with new skills and evolving topics such as experimental design for outcomes studies, as well as health economic evaluation of tests. I believe this is going to be crucially important in the future as governments struggle with the increasing demand on healthcare resources – as well as patient expectations.
- What, in your opinion, has been the most important contribution you have made to the field of laboratory medicine?
At one job interview some years ago I was asked about the most rewarding contribution that I had made in my career. I had to reply that it was the times at which I had made a contribution to new knowledge or new technology. Today I think I would give a different answer, in that I feel passionately about being able to demonstrate the value that the laboratory services bring to the patient and health care provision in general. So my goal now is to try and change the way in which laboratory medicine is perceived, so that it becomes more highly valued and that there is an incentive to develop new tests and new technology. The consequence of this is that research strategies are more firmly focussed on producing robust evidence of clinical utility. I see the consequence of this being that the clinical biochemist will become more focussed on the clinical aspects of the job and spend more time on the ward, and in the clinic. This also creates new research opportunities for the clinical biochemist – not only basic scientific and clinical research, but also translational research – as there is a need for greater commitment to ensuring that new knowledge can be translated into better outcomes for the patient, more quickly.
- Are there specific aspects of practicing laboratory medicine that you find unappealing?
I don’t think I would want to go on record on aspects of laboratory medicine which I find unappealing! However I suppose this is the time to mention a few of my frustrations – and some of the challenges that these throw up. I think we can pride ourselves on developing extremely good analytical methods, and we have often been criticised for pursuing accuracy and precision to extremes. I have to admit that I have contributed to this analytical literature as well!! This has inevitably, from time to time, been at the expense of focussing our efforts on the impact that our service has on the patient outcome, and the broader issues of health outcomes – including cost. Point-of-care testing is a good example where I am convinced that progress has been held back because the “cost per test” is greater, as well as the fact that we have not addressed the challenges associated with the changes in the clinical practice required to make best use of the rapid result. You may argue that it is not the job of the laboratorian to get doctors to change the way they do things – but I would disagree! The patient comes first for all healthcare professionals.
I am also concerned that our service is regarded as a commodity - a misguided perception for which we all share some responsibility - where the drive has been to reduce the cost of the test – rather than think in terms of the whole patient outcome. This is one of the greatest challenges for the future – to create an incentive framework for the diagnostics industry to develop new tests and new devices within an environment that considers the value of the contribution – rather than simply its cost.
Look at this from another perspective; we need to take a broader view of the meaning of quality in laboratory medicine.
- What were some of the most rewarding and/or challenging moments of your career?
The most rewarding time is always “getting results” in research studies – proving the hypothesis you set out to prove! There are always challenging moments! However one challenge was ameliorated to a degree when I realized that it was OK to admit that I didn’t know the answer to every question!!
This is quite a difficult question as there have been lots of rewarding times, and lots of challenges – and to me that is the enjoyment of my career. I would probably have to say that one of the challenging and also rewarding points of my career was leading a team to obtain the funding for the building of a new laboratory at the London Hospital. I should point out that it is a very old hospital in the East End of London and the first laboratory was in the main block of the hospital – in one room that eventually became the office of the Professor of Hematology! As the laboratory services grew, new space was added – but in different buildings such that eventually it occupied space over three blocks (in US terminology!!). The new laboratory cost $70 million – and opened last year, is purposely built on three floors and incorporates all of the specialties, with a large multidisciplinary automated laboratory, and a multidisciplinary molecular laboratory.
- How would you recommend achieving an optimal work/life balance?
If you asked my wife she would say that I am incapable of answering this question, and that I certainly don’t demonstrate any experience on which to base a sensible answer! I think my answer would have to be framed around defining your work and life goals and developing a strategy that enables you to achieve these goals – with those people you want to share your life with. My family is very tolerant and so, I am allowed to work long hours!!
- What excites you about practicing laboratory medicine everyday?
- What are your predictions for advances in laboratory medicine and/or your area over the next ten years?
There is going to be an explosion in new markers and it will be essential to determine what role each can play in patient care as their introduction is increasingly going to be based on the value that they bring to the patient, to healthcare provision and to society. I also believe that advances in delivery technology and miniaturization will mean that there will be more point-of-care testing, to the extent that the role of the clinical chemist will increasingly become that of a knowledge manager, supporting care givers and patients using the technology.
- What do you see as the challenges facing young scientists in laboratory medicine?
I think there will be an increasing demand for translational medicine research and this requires scientists in laboratory medicine to become more involved in the clinical team delivering care, spending less time in the laboratory. This will help to demonstrate the value of laboratory medicine.
- What specific goals would you recommend that young scientists in your discipline set for themselves? Any suggestions on how to achieve them?
In addition to core knowledge, I believe that the clinical biochemist needs to develop a portfolio of skills founded on research, clinical and leadership skills; basically to be able to work closely with clinicians and care givers as a team, and to be able to solve problems. Many will tell you this is a time of considerable change and so the clinical chemist needs to be equipped to deal with change; if you think there is a better way forward to address today’s challenges in health care then take a lead in the process of change. Much is made of the need for clinical leadership in laboratory medicine; there is no better time to develop the right attitude of mind, and the necessary skills. You will have heard many people say that every challenge is an opportunity; I think the key to a successful and satisfying career is to search out, and take on, the opportunities that present themselves.
- Describe how you have been able to give back or contribute to the organizations and the profession in general through your involvement in AACC.
Interestingly, my first head of department warned me when I started my Masters course training that many of the other students had ‘better degrees’ (which was very true) but that did not matter; he advised that I should always ensure I asked a question every week – to get myself noticed!! My second head of department stressed the importance of publishing good scientific work. My first role for the ACB was as the secretary of the regional committee; I missed out on the chairman’s role because I moved to another region! I was invited to chair the ACB’s Education Committee; luckily it was at a time when there was a need to review skills and competencies, and so we were able to create a new education programme. Later I was invited to be the Association’s Chairman – a bit like the AACC President at the time – and later its President. En route I was also elected as the first scientist on the Royal College of Pathologists Council. In my role as ACB Chairman I sought to develop a closer relationship between the ACB and AACC, for a number of reasons.
In terms of AACC I started attending the national meetings, and presenting posters in 1980. I also started to publish papers in Clinical Chemistry. Whilst the AACC has many international members it does not have a history, until recent times, of recruiting international members on to its committees, etc. I was fortunate to be able to travel to the national meeting every year, to talk at the meetings, etc., and this may have contributed to me being invited to join first the editorial board of the journal, then the Oak Ridge Organizing Committee. Later I was asked if I would be prepared to stand for the Board of Directors. This produced an interesting experience because, as part of my induction I was told that I was now to consider myself as an AACC member – not an international member! However in the subsequent months and years, the most common questions were ‘how do you deal with this issue in the ACB?’ or ‘how is this dealt with in Europe?’!! I think I was able to help the AACC in a number of ways, e.g. I took LabTests Online back to the ACB and suggested that they consider translating it into English (!!) – units, etc. Mike Hallworth, another UK AACC member has led this initiative with huge success and, more recently, we were able to help the Australians set up their own LTO. I also helped to set up: (a) an annual AACC Lectureship at the ACB’s National Meeting at which the AACC President attends, and (b) joint AACC/ACB symposia. Selfishly, I have also met and developed great friendships with a large number of AACC members and their partners – which perhaps goes back to the work/life balance question!!
- How did you get started in these organizations and what advice do you have for young people wanting to get involved?
I think one’s attitude to this will evolve as your career evolves. As I said earlier, my first head of department was essentially saying ‘get yourself noticed’ – quite a harsh, but practical piece of advice – for a shy rooky! If you think something needs doing - then do it; and if you get asked, then accept – as long as you feel you have the time and the competence (or are prepared to learn).
- Do you have any other specific comments or advice that you like to provide to the members of SYCL?
Developing a career is a bit like learning the rules for living a good life; whilst you may have your own personal goals you also have responsibilities in society. If you are going to become a clinical chemist, then learn as much about the professional environment in which you are going to work – because that is where the career opportunities for the future will take you.