Welcome to Transformational Thinking for Health Leaders. I'm Dr. Fiona Day, EMCC Master Practitioner, Coach and Mentor and a registered Chartered Coaching Psychologist with the British Psychological Society. This is a podcast that will help you meet your most complex leadership challenges and transform your perspectives, helping you to become a more effective and creative leader with a deeper understanding of yourself and your own world of work.

I'm committed to transforming health outcomes through my work and to supporting and developing outstanding medical and public health leaders who are able to thrive in complexity and chaos, bring clarity and compassion to those they serve and improve health outcomes whilst also taking care of themselves in order to enable their own best work. I hope you enjoy listening to today's episode. Professor Laurie Tomlinson is a National Institute of Health Research, NIHR Research Professor at London School of Hygiene and Tropical Medicine and a former consultant nephrologist.

She's seeking to use real-world evidence to address evidence gaps in clinical care. Welcome to Transformational Thinking for Health Leaders, Laurie. Thanks for having me.

Thank you. So, Laurie, tell us a bit about your early career and your clinical career and we'll kind of move on from that. So, I had a fairly conventional training in internal medicine.

Looking back now, it all seems as though it was very clearly designed, but obviously at the time it was a bit of a mess and I didn't know what direction I was going in and I wasn't sure which speciality to choose and things were very random, depended on which colleagues were nice to me at the time. And I also took quite a lot of time out, so I had a gap year. Before I became a registrar, I wasn't sure whether to continue in medical training and then I did my PhD during my clinical training as a nephrologist.

Wow, so you were kind of interested in the academic side back then, but kind of searching around trying to decide what to do, but it sounds also like kind of running that academic training, the PhD, alongside your clinical career, which must have been really quite demanding. What did you do your PhD in, Laurie? Again, that makes it sound like it was all very planned and organised, but it was nothing like that. So, I was doing my clinical training and I'd been moved on my rotation down to Brighton and I really liked living in Brighton.

It was a great place to be and I thought, how can I stay here longer? And I was offered a PhD, which was not in a topic I was interested in at all, but I thought, well, if I take this, I can have some more time to figure out what I want to do. So, I did the PhD and it was very interesting in some ways. It gave me a lot of time sitting in a room reading papers and thinking about how what we measure, what we study gets translated into evidence and that was what I got out of it.

It was nothing in relation to the particular topic, which was about measuring blood vessel stiffness in patients with kidney disease, but it was that that I really took from it and that was what was the thread that joined up all my earlier... I was always interested in epidemiology and social impacts on health and the nature of evidence, really. Yeah, fascinating, isn't it, how those foundations for what you do now were laid down really early on in your career as well. Thank you for sharing that.

And I suppose in terms of either thinking about how you did make that transition into epidemiology and into research, and I know that you shared the BNJ careers article, the interview with you where you comment about working with a lot of epidemiologists and everybody's wearing Birkenstocks and jeans. I thought that was really funny and I'll pop the link to that in the show notes. Tell us how you made this transition to be an epidemiologist, Lauren, and your kind of unusual decisions that you made at the time in terms of career direction change.

Yeah, so again, it was a sequence of problems and failures that led me to get really where I wanted, which was incredibly fortunate. As I said, my PhD, I was relatively successful, I suppose, but I was not really interested in the topic and I still didn't know what I wanted to do, but I was approached at a conference and offered a clinical lecturer job in Cambridge or rather asked to apply for it. And so I did, but it was purely uncertainty about my future that really led to that.

And I was lucky enough to get it. And again, that was a really fortunate job because it gave me a lot of time to think. And I remember I applied for a grant.

I had a very senior nephrologist, my mentor for the grant, and I didn't get in. And I gave it to her to read and I said, why do you think I didn't get this? And she read it and she said, it reads like you don't believe in it. And I thought, I don't believe in it.

That's so true. That's exactly what the problem is. And roughly the same time, my boss said to me, you need to believe in, when you get up in the morning, you need to believe in what you're going to do for the day.

You need to be excited about it. And those two things coming together made me think, I'm just not interested in this. It's not going anywhere.

It doesn't mean anything. It's not going to make any difference to health. And so that kind of set me on the path of thinking, OK, I'm just going to pursue what I am actually interested in, which was about evidence more broadly in relation to drug use and prescribing and in particular drug side effects.

And that set me on a track of eventually applying to do the MSc in Epidemiology at the London School of Hygiene and Tropical Medicine. And so I did that post PhD, which is a very unusual thing, but actually not that unusual at the London School. There are a lot of oddbods and misfits.

And it feels to many people like an incredibly, a wonderful environment because of this career diversity of backgrounds and interests. And I absolutely loved my Masters. I thought the work was so fascinating and I was doing exactly what I wanted to do.

And so when I finished, I started applying for funding to continue in that area. What a fabulous story. So there's something around, I can't remember your exact wording, but kind of like feeling your way, making mistakes, applying for grants, not really being that committed, getting the feedback from the unsuccessful funding around.

Actually, you need to kind of really feel the passion and the hunger for it, and then starting a process of trying to find out what that actually was and then finding it in the Masters. Like you say, going back and doing the Masters after the PhD, but it sounds like that was a really great experience for you. So what kind of happened then after the Masters and the next chapter? Yeah, so that was when I took some of my most radical decisions.

So by that point, I had my CCT, so I was eligible to work as a consultant, but I was still in my clinical lecturer post. I'm really well supported by my boss in Cambridge, Ian Wilkinson, who was incredibly understanding of my wibbling. But when I finished at the London School, I knew I wanted to continue in that area with the experts I was working with at the London School, so in particular Liam Smith.

And I put in an application to Wellcome, but the senior people at Cambridge, not my immediate boss, but the senior people at Cambridge wouldn't let me do that if I wasn't applying for the position in Cambridge, and there were a lot of political difficulties at that time. So I, in the end, decided to simply resign. And again, I was so fortunate.

People were saying, you know, you can't resign. And they offered me a one-day-a-week job so that I didn't have a big hole in my CV. So I did that and managed to do some freelance and some lowcoming, and then fortunately, I got the funding, so I was able to start full-time at the London School.

But it was very tenuous. It was a risky decision. I could very well have not got that funding.

And in fact, I did put that application into two grant bodies, one of which Wellcome funded it, and NIHR said, we already know this and didn't send it for review. So I was incredibly fortunate. So there's something there, isn't there, in terms of, like, having a couple of options, but these are quite difficult, risky decisions, like you're saying.

You must have had a lot of kind of courage to do that, but also it sounds like people were generally quite keen to support you, notwithstanding the politics. And so did you feel hungry for this one, then, the one that you got the Wellcome Trust grant for? Oh, it was so wonderful. In contrast to all of the uncertainties and just lack of enthusiasm that I'd had before, the day I got that grant was so incredible to be offered this opportunity to spend a few years working on a topic I felt really passionate about, that I really cared about in an environment I wanted to be in, with people I knew I would learn a lot from.

It was joyous. It was so wonderful. And, yeah, I think that's the theme, really, of the whole of my career.

I never felt I was good enough to do the work that I wanted to do, even though, really, I knew what that was all along. I was, you know, from my very early junior medical days, I'd realised what I wanted to do, but I thought I'll never be good enough to do that. I'm not one of the clever people.

And so I hovered about taking the more conventional decisions, but eventually, when I summoned up the courage to do what I really wanted, it did work out. Yeah, that's wonderful, isn't it? And I suppose how did you find that courage then? Laurie, how did you, you know, how did you dig deep and find the courage to believe in yourself? Because it was something that, like, many, if not most people, struggle with at multiple times of their careers. How did you do that? Well, I was lucky in that, you know, there were practical things about it, that it was easier for me to make that decision than other people.

Like, you know, I didn't have to find a lot of money for a mortgage at that time. I didn't have young kids. So, structurally, it was easier for me to take those decisions.

But, I mean, I do spend a lot of time talking to junior trainees who aren't happy and can see the direction they want to go in, but not quite clear how to get there. And, you know, often it's about making little steps to build a bigger path. And that was what I was lucky enough to be able to do.

You know, I'd filled in so many little bits of the paving stones that eventually it wasn't so hard to make that big decision. And also, I knew I wasn't going to be happy staying where I was. And so, I thought, well, if this doesn't work out, I would have to find another path anyway.

So, I might as well just jump. Thank you for sharing that. So, the welcome grant then, sounds like you really enjoyed that, got a lot from it.

What were you doing at that time? And then what happened next? Yeah, so what that work was about, was about using observational evidence to look at the adverse effects of ACE inhibitors and angiotensin receptor blockers. And when I started the work, you know, coming out of my medical registrar years and spending a lot of time in casualty admitting elderly comorbid patients who had become very unwell, it seemed as though drugs were the cause of all the problems. And it seemed as though with good quality evidence, we could improve prescribing and really make a big difference.

And that was what I wanted to do. But actually, that wasn't the way the research took me. You know, as I did more and more studies, it was clear that actually what we were observing as doctors is a form of bias.

You know, we're constantly seeing very sick patients taking lots of drugs in hospitals, so we blame the drugs. But actually, it's the fact that they're very sick that is the underlying problem. And actually, the drugs make little difference.

And the harms are, you know, if they're not observed in the original randomised controlled trials, for most cases, they're probably not that big of an issue. And so what I was actually ended up saying was quite contrary to what a lot of people believed. And at that time, there was a big push across medicine as a whole to try and improve treatment of patients with acute kidney injury and improve the prescribing relation to that.

And so I ended up being a real lone voice saying, hang on, I think we've got it all wrong. And some people were incredibly supportive. Some very senior people believed me and felt that my comments were worthwhile.

And there was a lot of pushback and some very, very negative pushback. And one senior cardiologist threatened to report me to the GMC. And it was all an interesting time.

But I think the pendulum's largely swung in the direction that the research showed in the end. And I think that now we're in a much more balanced position of understanding the benefits of treatment and that perhaps having a slightly less simplistic view that so much of the chronic problems that we see in acute medical services are direct results of the drugs. How fascinating and how challenging to be challenging the status quo.

It's very difficult, isn't it? And I can hear also that kind of pushback from other colleagues as well. But now, with the benefit of time, there's something around the consensus is more aligned to what you were finding at that time. And so what did you do next then, Laurie, after this? Well, I was coming towards the end of my funding and thinking about what to do next.

So I had a few ideas for big grants, but then we went into the pandemic and that really shook up everything. And so a group of my colleagues at the London School, we ended up working very closely with Ben Goldacre's group in Oxford to set up Open Safely. So it was a big platform enabling research into COVID-19 using the GP record, hospital data, COVID data and mortality data and a few other pieces of information.

And so we dived into this very intense period of a couple of years of just working extremely hard on a lot of epidemiological projects, trying to provide evidence to better manage the pandemic. And what did you find or what did you conclude? Well, I had a kind of interesting role in all of this. So at the beginning, Liam Smith, who is the leader of our research group and Ben Goldacre were the people who set up Open Safely together.

But not long after the start of the pandemic, Liam moved on to become the director of the London School of Hygiene. And so I kind of took over his overseeing role of all of the research that was being done in Open Safely from the London School. So there was some really important work that we did.

Right at the beginning, we described health conditions that were very strongly associated with severe outcomes from COVID-19. And that was very influential in the early phases of the pandemic. And a lot of the work I did was around the risks of living with children, which is a kind of surrogate marker for the potential risks of being in school.

And also I used my background as a kidney doctor because kidney function was clearly a very strong risk factor for mortality and severe outcomes from COVID-19. So a lot of the work we did was linking the UK renal registry, looking across the primary and secondary care data and outcomes. So just trying to provide a lot of information in relation to kidney disease specifically and thinking back to wave one of the pandemic and the appalling toll of death across dialysis units and among transplant patients.

It felt absolutely essential to try and do everything we could to provide better evidence. And were you still working clinically at that time? Yes. So through all of my time at the London School, I carried on working point two FTE as a nephrologist.

And so, yes, I was carrying on doing clinic mainly obviously remote during the pandemic, which was helpful because it gave me an insight into what was going on in the health service. But obviously my experiences are so different from most health care workers who were really had a much, much more difficult time. I think I was, yet again, I was incredibly fortunate to be in the position I was.

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And were you, you know, at that point then starting to influence policy? Like how, what were you doing with the outputs from your findings at that time? I think the outputs of our group, I don't want to claim that they were mine. They were very much a team, a team collaboration, a really, really big collaboration across, you know, not just Oxford and London School, but other universities as well. But yes, they were very important in lots of, lots of policy about, you know, who got shielded, who was prioritised for vaccination, looking for adverse effects of the vaccines and looking for effectiveness of the vaccines.

So a whole range of different pieces of evidence that did have quite a big impact. And one of the most interesting things that we did was in a multi-university study called Convalescence, we worked directly with the National Institute of Health and Care Excellence on the Living COVID-19 Guideline. And that was a really valuable experience of working directly with policymakers and seeing what real-world evidence could do in that kind of rapid turnaround situation.

That sounds fascinating to be kind of spanning everything from your kind of clinical care at that time to being able to influence at a national level. And where did the NIHR role come from? Was this after COVID or during, towards the latter end of COVID, was it? Yeah, so towards the latter end of COVID, the opportunity for applying for the research professor funding from NIHR came up. And I thought I'd be interested to apply.

You know, it's targeted at, I mean, it's targeted at a very wide range of backgrounds, but, you know, a typical person who's a clinical academic. And I thought about what to write and I had a couple of ideas. And then I just thought, what all of the work that we've done with NICE just thought, this is worth expanding on, this is really valuable, this is useful.

But it was totally left field. But luckily, the head of data at that point, Felix Greaves, was keen to support it. So I sat down and in two weekends, I wrote the entire application of what providing near real time evidence on particular topics alongside different work streams that NICE would look like.

And it's one of those ideas that kind of comes fully formed and then you just write it down. And I love this kind of sense of your kind of, you know, what you described, the left field thinking, that kind of disruptive thinking, really looking at things from a different perspective. And where are the roots of that, Laurie? Like, is that something that you recognise in yourself, like go back in time or is it something you've learnt over time? That's a great question. 

I think I've always been difficult. But for a long time, that felt like I was a weird outsider, which explains, you know, why my early career was so difficult. But over the years, I've come to see the value in that.

And, you know, my Wellcome funding and then the pandemic basically gave me the confidence to think, this is a bit of a crazy idea, but, you know, they'll either like it or they won't. And if they don't, no harm done. So, yeah, I think it was just the combination of my growing confidence that enabled me to write that.

Yeah, it's really great to hear that it was there kind of in your head and you kind of managed to get it down so quickly. And then it was kind of somebody who got it and kind of really understood what you were trying to do there. And how is that going? What have you found in the last couple of years or so? What's emerging for you around that? So, professionally, it's been fantastic and I feel incredibly lucky to have had the opportunity to do this work.

Seeing how the processes and the bureaucracy within an organisation, you know, where people are really committed to trying to make a difference and improve health care. Seeing, obviously, all the benefits of that, but also the restrictions that they're under compared to academia. And then thinking, how can we run projects that are going to help that? And each cycle of the work, I feel like we're getting a little bit more insight and a little bit closer to what it means to do really useful work in that kind of context.

And huge opportunity. I mean, obviously, with huge data linkage, with growing use of AI, with more normalisation of real world evidence, there is a huge potential for health care decision making to be much better informed. So, yes, it's been a fascinating process.

It is also, you also begin to see the difficulties and limitations and trying to work out how they can be overcome. Sounds very kind of emergent and, you know, I guess you're crafting your way through something that's very innovative and different ways of thinking about things not really been done before. But it's great to hear this kind of sense of a kind of growing confidence in yourself.

And I suppose I'm curious about you as a leader, Laurie, and what you've learnt about that, whether that's something that you could just share with us, please. I was coaching with you and previous coaching as well, and there's this mindset shift from I'm not good enough. I wouldn't be here if some people didn't think I had interesting things to say or something to contribute.

And as you continue to rise up the ladder, even if you feel like it's almost despite yourself rather than because you're pushing yourself up it, increasingly you think there must be something worthwhile about what I'm doing. And so, yeah, increasingly you have the confidence to put forward your perspective or to contribute what you have to say on a particular topic. But I think that that has been a slow process. 

And I mean, that's obviously something I see in a lot of people at my level and particularly women. And something I really think is valuable, trying to encourage other people to see that value in themselves and put themselves forward and their opinions and comments. So I love how you're then needing that to kind of support other people as well. 

And, yeah, I wonder if there's something about the kind of women in leadership roles as well. And do you feel that you bring a particular perspective in that capacity as well as the kind of challenges that you just described? I think I have my outsider's perspective. You know, there is still a core of medicine which is confident, privileged people rising to the top.

And I hope that what I can provide is someone who says, I did things differently and I didn't fit in and we all felt very odd and wrong. And yet it was all worthwhile and it was going somewhere that feels valuable and useful. And, you know, those are the people who somehow find me and the people who are similarly lost in their careers and think that what they have to contribute is not necessarily worthwhile.

And I hope that I can support some of those people to see their own value and move on. Yeah, that's nice, isn't it? The kind of giving back, I suppose, from this kind of more mature perspective yourself in terms of more years of career behind you to be able to be that person for other people and what you might have needed yourself at that point in time too. And I guess in terms of where you're going next, Laurie, in the kind of cutting edge of your own research and your research thinking, what's kind of emerging for you around that? Well, that's the hardest question of all. 

So I can see tremendous opportunity to continue the work I'm doing now. Healthcare analysis has moved on so rapidly with better linked data and better research methods. We should soon be in a position where it's possible to have really bespoke analyses done very quickly to inform any particular, for example, guideline or health technology appraisal.

So that's within our grasp if we can put some resources towards it. I think whether I will end up continuing to work in that field is less clear, but I'm enjoying it at the moment. So is that, just to help me from my own understanding, is that like how we can use technology to undertake a systematic, rapid, very rapid systematic review at the kind of push of a button rather than a kind of six to 12 month process? Is that what you're referring to or if I'm misunderstood? Well, just to give you an example, NISA are very interested in inequalities in healthcare and seek to try and think about where those are and minimise them through guidelines.

But actually, there is no, they don't necessarily use any new data to try and address that at the guideline stage. They might look at published data, but in general, the technical team are incredibly busy. They may not have time to produce that new data.

But what we were able to do with our last guideline recommendation was to look at the inequalities in prescribing across England in relation to the particular topic of the guideline very quickly. And identify, for example, that men were 50% more likely to be prescribed guideline therapy than women and that there were substantial regional differences with London being way ahead in prescribing recommended therapy. And so if you can highlight those inequalities, very much up to date data at the time you're developing the guideline, then you can think about how you can incentivise the guideline GPs or people working in primary care to deliver them to try and minimise those incentives.

So minimise those inequalities, which, you know, that kind of cycle could be done very quickly for each particular disease area. Wow, that's fascinating. I didn't know that that was being done. 

Things have obviously moved on since I was a public health consultant. I guess there's something around those clinical process measures that you're able to look at at the touch of a button with these massive data sets, aren't you? And then being able to design effective interventions based on them. Well, fascinating. 

Thank you. So, yeah, Laurie, thank you ever so much for being a guest and sharing your experiences and your academic career and the work that you've been doing and the thoughts about the future. It's been really great to chat with you and thank you very much for your time.

Thanks for having me. And you can receive three hours of free CPD through my health career success programme. And there's loads of other resources to support you as a medical or public health leader on my website, too.

I greatly value any feedback and to know what you would like more of. So please don't hesitate to get in touch with me at Fiona at Fionadayconsulting.co.uk to help me to better meet your needs. Thank you for listening and for your commitment to transforming health outcomes.