The Effectivity Masterclass

The first thing is: what's the gravitas — the status — of the person giving you the advice? Take "how I study as a medical student." There are loads of these now. To be honest, if you're the best medical student, blowing everyone else out of the water, how you study becomes quite interesting. If you're in the middle of the pack, I don't really care how you study. So when people talk about their success — their productivity — you have to ask what their skin in the game is: what is this person's role?

The second thing is that what's successful for them may not be what's successful for you. You might get really good advice on how to publish academic papers from someone who has terrible social skills and no life outside medicine — so that may not be what you're looking for. It's worth putting all of that in context. The intention of this episode is not to say "this is how you should do things." It's simply to say: these are some of the things that, both from my own experience and from watching others, seem to be useful — and it's up to you to evaluate them.

Whether it's a self-development book or advice from a person, people often read through and go, "oh, it didn't all work for me, it's rubbish." The intention isn't that it all works for you. The intention is that one little nugget works for you 1% of the time for the rest of your life — and that's a huge thing. I've tried all sorts over the years. Some people say you must get up at 3.30 in the morning and exercise. I tried that for six months and it was a disaster — for me. That doesn't make it a bad thing; it just means it didn't work for me. So with all these tips, the idea is that you try them and find out what works for you, because the optimal thing for you won't necessarily be the same as for me.

That's a long-winded way of caveating everything, because I'm really going to focus on people who want to be clinical academics — how you balance clinical work with publishing and being involved in lots of research. That may not be your interest. If you want to be an entrepreneur, a lot of what I'll tell you might be bad advice. You see this in medicine all the time, and it's frustrated me since I was a student: someone's a professor of something, they're very good in that field, and then they suddenly think they know about everything — all sorts of fields they're not experts in. Just be cautious of that.

A couple of things. The first is just doing the same as everyone else. A really simple tip I used all the time, which has worked well for a lot of people, is: always study one level up from what you're doing. If you're reading for your finals using exactly the same textbook everyone else is using, then however well you learn it, you'll know the same as everyone else. So when you're studying for your medicine finals, read MRCP books. When you're studying for your surgery finals, read FRCS books. You'll find the books are generally much better written, and you'll get insights you wouldn't have had otherwise. If you use the same materials as everyone, you're not going to stand out.

The other thing is this obsession with note-taking — "how I do my coloured notes, how I use my iPad." There's nothing wrong with that if it works for you. Personally, I found it really inefficient. I'd spend hours making notes and not much time learning. So I essentially made almost no notes and went to almost no lectures. I used textbooks and wrote all over them — but not to make notes about the thing, rather to help me understand it. Because the rationale was: once I've read it and understood it, I don't need notes anymore.

That may not work for others. But I see students — even postgrad students — spending a lot of time writing and making really neat-looking things, and then you ask them a question and they still don't understand it. The intention isn't to have nice notes at the end of medical school; it's to understand these things. There is good evidence that for a certain type of person, the act of writing notes helps them learn. For me, it doesn't — I need to visualise things and think about them, and notes are too slow. Find what works for you. It's back to the thing we said at the beginning: just because everyone else is doing it doesn't mean it's good.

Ultimately, you've got to become competent in whatever area you want to be competent in. Then you've got to decide what you want to be the best in the world at — what do you want to excel at? And you cannot use the same books and learning materials as everyone else, because it's impossible to excel that way. You've got to make conscious decisions about where you're going to step up. You can't do that in everything, though. Psychiatry, for example, was something I never got on with, so I didn't use any postgraduate text — I just wanted to pass and do the minimum. But for the things I was interested in, using postgrad textbooks as a medical student was super helpful. That's how to be a little bit contrarian, and how to excel academically.

This came to me almost by luck. It was much easier when I qualified to flick between specialties — it's harder to change your specialty now. But I moved around a fair amount: I did obstetrics, then moved into pathology, then informatics and various things. One thing I found really helpful was that when you've already done a few years in one specialty and you move to another where you know nothing, it's quite easy to ask what would be considered dumb questions — because you're up front saying, "I don't really know anything about this subject."

And I realised quite early on that a lot of the dumb questions are really important questions. That's what helps you, both in your clinical world and in your research. This does sometimes get misconstrued, because some people ask "dumb" questions to show off — a question they could have Googled and answered in five or ten minutes. Let me give you an example. Say you're going into obstetrics and you ask something about pre-eclampsia. Asking what you think is a clever question — "does aspirin help?" — is silly, because you could just look that up. But asking, "why doesn't the trophoblast invade properly?" is a really fundamental question. All the researchers in the field will start talking about HLA and cell-surface markers — but the honest answer is, we've no idea. And if you could solve that, you'd probably fix preterm delivery, pre-eclampsia and growth restriction. You've suddenly stumbled onto a fundamental question.

I think so. What's really the main thing in obstetrics? Preterm delivery. So why do we go into labour? We don't know. That's a fundamental question, and it clarifies things a lot. It's this idea of stepping back even in your clinical world — the strategy piece. Don't get down a rabbit hole too quickly. What's the big picture? What are the main questions you need to answer?

The other thing that's super useful is that when you go into a field, try to work out your own explanation, or map, of that area. When I trained — originally as an obstetrician and fetal-medicine person, then into pathology for paediatric pathology — I unfortunately had to do adult path and the exam before I could go on to the paediatric stuff. And I knew nothing; I'd had no interest in it at medical school. One area that was particularly tricky was renal pathology. There are huge textbooks on it, and I found it frustrating even to read through. So working out my own map — almost my own classification system of glomerular disease — was really helpful. It was just to help me understand it in my head. But what I've since found is that almost every trainee who comes through doesn't really understand the principles of renal pathology, because they've gone straight into the books that classify according to the Oxford system or whatever, and they don't understand how the whole thing fits together. Sometimes you say, "how about thinking about it like this?" and they go, "oh, that's quite simple, isn't it?" There are lots of things in medicine like that — you get sucked into the weeds too quickly. So force yourself to keep coming back: hold on, do I understand the big picture here? Now I'll drill into the next bit.

This is really interesting, and I think it's going to change a lot in future years, given how medicine is changing. This is just my personal view. The training system we have at the moment is 50 years out of date. It makes no sense to have a College of Surgeons completely separate from the medics, completely separate from the pathologists. The reason we still have this system is primarily the colleges — they control who's in the training programme and who's in their college. That worked when people rarely needed skills across the spectrum. But what you really want now is clinicians with a skill set. It would be extremely useful, if you were training as a surgeon, to have some elements of anaesthesia, some pathology, some paediatrics. It doesn't really matter what — it's the idea of a strict syllabus you can't deviate from that's the problem. If you now want to do some anaesthetics, it's "yes, you can apply for a one-year anaesthetics rotation" — that doesn't make sense.

It would be much better to get rid of all the colleges, have one college, have modules for competencies, and let you choose your training depending on your competencies. The market of medicine would then determine whether that combination is useful. If you're a surgeon who's trained in vascular surgery but has also done some plastics and some anaesthetics, and that's a really useful combination, people will want to employ you. If it's a terrible combination, no one will, so you'll change and do something else. That would make people much more fit for purpose. Hospitals like Great Ormond Street, where I work, are super-specialist. We've got three radiologists who just do paediatric chest radiology. They're brilliant at it, but anything in any other part of the body, they say, "I can't comment on that, that's a different department."

There is a role for that super-specialist, but sometimes you also need a general paediatrician to go, "hold on — how are we going to manage this whole patient?" Not just their renal disease, not just their cardiac disease, but the whole thing. So it's tricky for medical students and trainees to get that mix right. And leading on from where we started in the last podcast: one of the things that's going to become much more important in the future are skills that aren't in medicine at the moment. There is absolutely going to be a need for clinicians across all specialties who are trained in informatics, who understand algorithm development, who understand user-interface design. At the moment there's no system, no structure, for that — and it's absolutely required.

Well — okay. I've enjoyed everything I've done. But if I were starting again now, because of the changes, I certainly wouldn't do the same things. Radiology and pathology as we know them are finished, because of everything we discussed — the impact of tech and AI and image analysis. The areas that will become even more important are everything around informatics generally. And I'd underestimated, as a junior doctor and medical student, the importance of understanding something about management. I don't mean that in a dreary hospital-management way. Take innovation as an example. We touched on this a little last time but didn't really discuss it. Lots of hospitals say, "oh yes, we're becoming innovative now." You ask what they've done, and they say, "we have a PDF on our website now." That's not innovation. To do innovation properly there's a big structure. If you go to big companies like Microsoft or Apple, innovation isn't a little bit they do on the side — it's a core function, right through from capturing ideas, landscape mapping, user-interface design, creativity, coding. That's just the tech example, but it's exactly the same for medical devices, or new surgical procedures, or new materials. And you can be trained in how to do those tasks.

When I was an SHO I actually started an Open University MBA. I didn't finish it — I did the first couple of years and got the certificate bit but didn't complete it. But it was super useful, just for letting you push through the nonsense you hear in management meetings. You understand the language, and you can do what we just talked about — step back. You listen to someone waffle on for five minutes and say, "so, you think we should do this." That's a helpful skill. You also realise you can have much more impact on clinical care by influencing the system — the ward, the hospital, the organisation, the college. Just standing on a box shouting generally doesn't do much good. You've got to influence the system.

So I'd absolutely try to have more of a portfolio if I were training now, and start getting some training and expertise in innovation, or in health systems — how do you implement things? That's one of the biggest frustrations we found with some of the early tech stuff: you can do a lot of the tech development really quickly, but how do you implement that on a ward when no one's interested, everyone's busy, and they're saying, "we've done it this way for five years, it's fine"? Suddenly you realise you're not equipped to do that. When I was training, a lot of the focus was on remembering things — that's silly now. It was always silly, but it's even more so now. What's the point of remembering a list of things you could look up? The only thing you need to remember is where you can look things up. And a lot of the tasks will be taken over — even managing patients, making diagnoses, listening to heart sounds. But the bigger questions — what's the strategy here? how do we get this done? which of these things should we focus on? — those are really hard. They're hard for humans, and they're really hard for systems to take over. That's where people will be able to make the most impact.

One thing that gets talked about a lot is meta-skills — skills that let you do other things. The first, for sure, would be to schedule and spend time learning how to learn — for you. Not how I learn, or how you, Mustafa, learn, but for you. You need to know yourself, work out what's best for you, and stick with it. That might include a range of other things — managing yourself, so maybe meditation, or exercise. But learning to manage yourself is the first thing.

The second would be to actively think about the other area you're interested in that would go alongside your main clinical interest. Say you definitely want to be a surgeon — great. So what's the other thing? Are you interested in coding? Then focus on developing those skills and think about how you'll bring that into surgery. Are you interested in being a maker? Then devices might be for you.

The third thing, right from early on, is to do something around management in the broadest sense — and I don't mean old-fashioned management training, but something around management, innovation, leadership, whatever it is. And in general, avoid anything in healthcare, because for me the biggest benefits come from learning in other industries. Other industries do things really well, and there's a significant opportunity to learn from them. You'll find it more interesting, because it's different from your daily task, and you're more likely to get an insight you wouldn't otherwise have had.

As an example: there's a group in the UK looking at healthcare responses following COVID, and some of the most interesting people I've spoken to in that arena run large grocery chains — because they're really good at managing logistics. They can't believe that in the NHS nobody knows where a thing is. Which we don't. Go to most hospitals and ask, "how many packs of so-and-so are on that ward?" and someone will say, "hold on, I'll go and look in the cupboard." Any logistics or supply-chain company would fall off their chair: "what do you mean you don't know where everything is?" So the more exposure you can have to those other things, the more of a lever you have to actually make a difference to the healthcare system. Just reading another chapter of a book will not make you the best in your field.

When you get appointed as a consultant surgeon, it's assumed you'll be a good, competent surgeon — your complication rates and everything else will be checked. There's no point then saying, "I'm a good surgeon, give me a pat on the back," because that's the whole point of being a consultant surgeon. What I want to know is: what extra do you bring? I know you're a good surgeon — I wouldn't have employed you otherwise. What else do you bring to the table, for the hospital, for the healthcare system? So having that focus on the other thing, where you can leverage what you're doing, is super important.

I think we're much better now at having broader views and learning from others than when I was training. Where we're not good is that we've been brought up to say medicine is different. Everyone thinks they're very special in medicine. "Oh, healthcare is different, we can't possibly use the thing Sainsbury's uses, we can't possibly do the thing Ford does." But when you push people — why not? Why can we not use that? It's quite good, isn't it, and it's ready. Often people don't really have an answer; it's just, "oh, but it's not designed for healthcare." You see this absolute nonsense in devices: a healthcare monitor that costs £4,000, and it's the same as a monitor you could buy off Amazon for a couple of hundred quid — but it's got a healthcare sticker on it. So we make it worse by saying healthcare is very different.

Partly, too, because medicine takes so long to train, we tend to get people into medical school straight from school. That means you end up with a group of people who've all come through the same training system, and it's quite difficult to bring in additional views. In retrospect, I'd have spent more time actively engaging with people outside medicine, in that periphery. What medicine is very good at is collaborating — still not great, but good compared to many other industries. It's pretty easy to run a multicentre trial, to do something across a region, to implement something once you've decided to. The standardisation part — using protocols — we're quite good at.

What we're not good at is thinking about the system instead of ourselves. And by "ourselves" I don't just mean the doctor, but the clinic or the hospital. We saw this with COVID. The simple question, "how many patients do we have in hospitals in the UK today with COVID-19?" is almost impossible to answer. You'd think you could answer it in two minutes — obviously every hospital records this the same way, right? But no. Almost every hospital has a different IT system; some use paper; some only include patients with a positive PCR, others include patients who presented with a history, and so on. When you drill down you think, my God, we're not standardising the way we record things, because every hospital has developed something that works for that ward without thinking of the bigger system. You'd never get that in other industries. You could never have a mobile-phone industry where every company develops things only for their own phone — there'd be no ecosystem, the phones couldn't call each other, you couldn't have apps. We haven't quite grasped that we're part of a bigger system. And if we all did things in a much more standardised way — tech, operations, whatever — the byproduct is that you get a lot more understanding, and research happens much more quickly.

It's back to the thing I mentioned before. If you spend time on something that develops you — that gives you a skill or benefit that will help you for the rest of your life — that's a no-brainer. It always amazed me, even as a student: you get medical students spending 50, 100,000 pounds on their training, and there'd be a book for 30 quid and they'd go, "oh, that's too expensive, I'm not getting that." If I said, "pay me 30 pounds and I'll implant into your brain a piece of software that lets you function 1% better for the rest of your life" — is that good value for 30 pounds? Obviously yes. Well, buy the book to implant the software.

So for me, reading — and I don't mean novels, I mean the types of books we're going to talk about — isn't about reading them for fun. You're reading to find the nuggets. And the nugget for me may not be the nugget for you. You just need one thing. That transformed the value proposition in my head: I'm just trying to find one useful thing. Some books, you think, "wow, that's amazing," and then a few pages later, "wow, that's amazing" again. Other books, you read the whole thing and get nothing. So suck it up — you didn't get anything out of that one, but the benefit outweighs the risk.

Before we get onto the book part, maybe it's worth covering a couple of things you asked me last time — some semi-random tips, particularly around clinical academia.

We'll start with the thing we briefly touched on last time. You asked me what the single most useful practical tip was, and I stick with this: be obsessed. We're talking about your CV and your academic output here — let's assume you've decided that's important to you and it's what you want to do. Have a blank sheet of paper, and on it write down the thing you've delivered in whatever time period you're looking at. If the thing you're trying to do is get a research paper published, then I'm only interested in the publication. Show me the PubMed reference. The fact that you worked hard, stayed up all night, did all this — couldn't care less. It's irrelevant to me. Did you, or did you not, deliver the thing? Until you've delivered it, it's worth zero.

People come from school being patted on the back — "oh, good boy, good girl, well done for trying hard." I couldn't care less how hard you try. I couldn't care if you don't try at all. What I care about, from the CV and academic perspective, is the output. Once you've done the paper, you can tick it off. Until then, nothing. That was drilled into me by Kypros Nicolaides, who supervised my first postgrad work. It's useful for lots of things, not just academic ones. I remember trying to sort out a technical issue with some kit in the unit and telling him, "I've been up all night trying to do this," and he just said, "so you haven't sorted it, then, have you?" And it hit home. I see this all the time. I'll ask someone to do something, and two weeks later I ask what's happened, and they say, "oh, I emailed so-and-so but they haven't replied." But I didn't ask you to email someone — I asked you to sort out the thing. Your job isn't to do the first step and pass it on; your job is to finish the whole chain.

That was transformative, because you see loads of people, from medical students onwards, who get involved with research projects but never finish them. They never write the abstract, never do the presentation, never finish the chapter — and they've wasted a huge amount of effort, when it's often another 10% to do the finishing bit.

The other thing that's underestimated — and this comes up in a lot of, for instance, the Tim Ferriss books, Tools of Titans and so on — is: just turn up and do the work. That's a core thing. A lot of what we're talking about here is finding efficient ways of doing things, finding shortcuts. But sometimes people get over-obsessed with that and don't just turn up and do the thing. You see this with training from undergrad onwards — I'll use pathology because I see it now. People try all sorts of ways of asking, "is this going to be in the exam? should I read about this more than that?", looking at previous exam papers. The people who consistently smash the exam are the ones who just turn up and look through hundreds of cases, because that's ultimately a skill. It may not be the most efficient way, and I'm not saying don't also look for efficiency — but while you're being efficient, just turn up and do the work. You don't feel like doing it today? Tough. You don't feel like writing today? Tough. It's in your diary — you're going to write for two hours. That's what you do.

People also massively waste time throughout the day in small chunks. You need to be very efficient about what you do with your 15 minutes. You come to a clinic to be taught, the first patient doesn't turn up, and you've got 15 minutes. You can chat to your mates and pick your fingernails, or you can have a plan. I see this even in colleagues: "oh, the meeting's in 20 minutes, no point starting anything." You've got to become very good at task-switching, so you can go, "right, 15 minutes — perfect for this. I can read this thing, review this paper, start writing this paragraph." If you get more efficient with that, you can suddenly get two days' work done in a day. I'm not suggesting you work the whole time — actively schedule stuff. You might schedule that you're going to listen to music for 15 minutes; when you get the 15 minutes, put your headphones on. You can actively schedule that you're going to blob out and have a coffee. That's fine, because you made a conscious decision. The problem is when those things become time-sucks — you were going to do something else and someone says, "shall we go for coffee?" and you waste two hours. Occasionally that's okay, but if you consistently do it, you waste a massive amount of time.

The last practical thing is to develop what some people call rituals — NLP practitioners would call them anchors or triggers. Develop a way of getting yourself in the zone; it massively helps your task-switching. Say you're giving a talk at a conference at two o'clock. For most people the whole morning's a washout, because in their head they're thinking about two o'clock — are the slides ready, and so on. Much better to train yourself: what's my ritual for giving a talk? I'll check my slides and have them in three places — a USB in my pocket, my laptop, and here. I know that's okay. And what's the trigger to get you in the zone, where you flip from Mustafa the medical student to Mustafa the presenter? By developing those little tricks, you can almost forget about the talk until 10 or 15 minutes before, then go, "right, now I flip into this mode." Now I flip into clinic mode. Those are really helpful.

And — sorry, the very last one for academic medicine — don't take yourself too seriously. You see loads of people acting as if their research on some particular cell-surface molecule in some particular disease is the thing the whole of medicine revolves around. You're trying to do important work, but don't take yourself too seriously. You also have to accept that you'll be rejected. I've been doing this for many years, have a good number of publications, and I consistently get papers rejected — so does everyone I know — and consistently get grants rejected. Suck it up; that's part of it. You'll get silly comments from reviewers who you think don't understand what you're doing. That's all part of it. Learn early on that if you can't accept that, you won't thrive in clinical academic medicine. Don't take it personally. You see people it's eating up — it's brewing inside them that so-and-so rejected their paper. You have to let that stuff go. It's gone. You've got to have some fun in what you're doing, and the only way to have a bit of fun is to step back and not take it all so seriously.

I just thought it was worth mentioning a few. A lot of these are probably ones people have covered before. As I said, I'm a big fan of Tim Ferriss and the stuff he covers. I don't think we need to cover those in detail, but I'd absolutely recommend, to anyone who wants a grasp of what we're talking about — when someone says, "what do you mean, books that have tips in them?" — Tools of Titans and Tribe of Mentors are very good ones. Interestingly, I find about 90% of what people say in those not very helpful, but I still find the books massively helpful because of the 10%. It doesn't matter that loads of it isn't relevant; you're trying to find the stuff that is.

There are a couple of others — not particularly obscure — that have stuck with me and made a disproportionate impact I didn't realise at the time. One is Extreme Ownership by Jocko Willink, who was essentially a Navy SEAL. The core thing is almost the blank-sheet-of-paper concept: it's your problem, suck it up, stop blaming everyone else and get on and sort it out. You have to take ownership of everything. If your teaching is rubbish for a certain specialty, that's your problem — it's not up to you to keep complaining that it's not very good; you sort it out. He gives helpful examples of how that moves into general life.

One that's relatively recent is The Infinite Game by Simon Sinek — you'll have seen him from TED talks; he gives great stuff on leadership. It's one of those books where you read it and look back at almost everything around you and go, "oh my God, yeah — I can see exactly what's bad about that." The concept is that hospitals and academia in particular are obsessed with being the best, the number one — "we'll be the biggest unit, the most whatever." And you realise that's not a good goal. The goal should be: I'll do better next year than this year; I'll continue to improve; we'll make patient care better — not that you stuff your colleagues who are also trying to make patient care better.

A slightly old-fashioned one that's been very helpful is David Allen's Getting Things Done — the GTD method. The thing that stuck with me most is the idea of mental RAM: you shouldn't be carrying around lots of stuff in your working memory. Have somewhere you can dump tasks. You think of something — "right, I need to do this today" — and the natural tendency is to try to remember it later. You need a system to get it off your brain. I've tried every kind of tech for this, and without doubt the one I keep coming back to is a folded-up piece of paper in my pocket with a pen. This works far better for me than anything else. I have this horrible, scruffy bit of paper every day; as soon as anything comes into my head, I write it down. Then every evening I go through it and put it onto my OneNote, so I can access it across all my devices. That concept of actively managing your emails and your to-do list has massively helped.

The last couple: there's Rolf Dobelli's The Art of Thinking Clearly, which is all about errors in thinking — a really interesting book. You realise there are so many catches and errors in the way we think. And the last one that's made quite a big impact on how I think is Thinking in Bets by Annie Duke. She's a professional poker player — I think this came from one of the Tim Ferriss podcasts, though I'd heard of her before. It's about errors in thinking from the perspective of game theory and poker. The core message — and you hear this all the time from people in management and hospitals — is that they confuse the outcome with the decision. A decision is made, the outcome doesn't turn out as they thought, and they go, "ah, so in retrospect that was the wrong decision." That's not true. Say there's a decision that has a certain chance of curing a patient. One drug has a 30% chance of adverse effects, the other a 10% chance. You give the drug with the 10% chance, and it turns out that patient has an adverse effect. People go, "ah, you should have given the other drug." But that's not how it works — you still made the right decision; it just so happened the outcome wasn't what you wanted. I found that extremely useful for deconstructing: was the decision correct, versus was the outcome correct?

And the very last book is Derren Brown's Happy — which has nothing to do with productivity. But if you like Derren Brown's style, it's a really good, philosophical book. A lot of it is around stoicism, but really it's about managing yourself, getting on with things, and not taking yourself too seriously.