Imperial → McKinsey → Mayo Clinic (US)

Firstly, thank you for having me on your show — I'm a big fan. So, my name's Ikram. I went to medical school at Imperial College in London and spent six years there. One of those years I was in the business school, doing the business management course as part of the intercalation.

For a long time I was debating and thinking about what I wanted to do in life. It's a common story you find amongst a lot of medical students — balancing different interests, different passions. The business school year really helped me expand my horizons and pursue different options. A couple of the interests I had, and continue to have, are technology and digital health, and the value of that in reshaping healthcare — more specifically, adding value at scale. That led me to work quite a bit with a lot of digital health companies in the UK, more on the business development side: looking at where they are right now, how they grow, accessing different markets. I was very privileged to work closely with some very interesting companies that really shaped my understanding of the business side of digital health startups — and also, as a career, what it would be like to go out and create your own startup, build your own company, and what the life behind the scenes looks like.

At the same time, I obviously had a real passion for medicine. Learning the science of medicine is what brought me to medical school. So I was always pursuing interests within medicine, be that research — more specifically, at the time I was very interested in HIV and HIV-associated malignancies, and did a couple of research projects at Chelsea and Westminster Hospital. And then towards the end of medical school I wanted to explore what it means to go into healthcare consulting: what does it mean to work for a consulting company? I explored those options with my medical elective period. At the same time I was answering a completely different question: if I were to stay in medicine, where would I want to practise? Where would I want to be in 10, 15 years' time, and where would be the best place to put me in the strongest position to fulfil my goals and vision?

That medical elective period was critical for me. We had about three, three and a half months off, and I was planning way ahead to take the most value from it. I ended up spending a month at the Mayo Clinic on an internal medicine rotation, a month at the Cleveland Clinic in Ohio in cardiology — another interest of mine — and then the third month with McKinsey in London, working with the London and Dubai offices for seven weeks, before starting F1 in London.

Those three experiences, slightly different between them, really shaped my understanding of where I wanted to get to. They factored into two decisions: number one, do I want to stay in medicine or not — and the answer was yes; and number two, where would I want to practise medicine, the US or the UK? That was well and truly answered during my electives, and led me to apply for residency in the US. I was lucky enough to match at Mayo Clinic, and I'm about seven to eight months in now.

My philosophy with all this is that one can plan and plan, but God is the best of planners. That's my 30,000-feet-level philosophy. With that in mind, the advice I give a lot of people is: don't do no planning at all and just think everything will fall into place. Rather, give yourself a general roadmap of where you want to get to, and put yourself in relevant positions and opportunities that could facilitate that.

That doesn't mean meticulously planning exactly where I want to work in six and a half months' time. It means looking at your life over the next four to five years and thinking, these are the opportunities I'm going to have. In medicine you're very privileged, because your life around work and training is already somewhat planned out. In my case, in third and fourth year I knew I had a three-month period in final year — how best do I make use of it? I have a lot of free time around medical school — how do I best make use of it? So there was a lot of planning, but high-level planning. The specifics were more about applying and seeing what happens, and then being flexible enough to accept failures when and if they came, and acceptances when and if they came.

They're two different mindsets, two different careers, so it's most useful to extract general principles from each. Let's start with McKinsey. For the McKinsey elective and summer internship, I'd really argue it's about reading around medicine — not just understanding the technicalities and the physiology you see in a clinic, but understanding how healthcare is delivered. A lot of the benefit I extracted was from the management year, plus regularly reading The Economist and other insights into how healthcare is delivered: what does it mean to deliver high-quality healthcare, how do you improve access, how do you measure outcomes? Having a real interest and the ability to talk about this — and then apply it to new examples — is what really shines out in an interview.

The McKinsey application process has a first test, the problem-solving assessment, which is similar to a lot of the exams you're used to. The second element is an interview. In the interview it's about, number one, telling your own story and synthesising it so you extract learning points and show that you're a leader, a team player, forward-thinking, able to solve problems. And number two, applying a lot of the information we talked about — healthcare from a delivery and managerial standpoint, cost, evidence-based, value-added care — to new issues.

Now, for the Mayo residency, and US residency more generally, it's a completely different ball game. It's about medical school performance, exam performance, obtaining US clinical experience, and being in a position to get letters of recommendation to strengthen your application.

More general values you can underpin — I'd say three or four. One is having a plan going forward and having goals. Number two is putting yourself in the right position with the right people. When you surround yourself with colleagues and friends who are thinking along similar lines, testing you and pushing you to think differently, that really shapes and broadens your horizons. There's a saying I really like: you're the average of the five people you hang around with. You want to be in a circle that's pushing your thoughts and broadening your horizons.

Number three is doing the hard work when and if it's needed. There are two types of people in this world: those who do none of the work but take all the credit, and those who do all the work but get no credit. There's a saying by Gandhi that there are more people in the former group, so it's better to be in the latter. So it's putting in the hard work and dedication when required, and seeing the fruits — even if they come, and even if they don't. Having that trust in the process.

This is a very important question, because it's all well and good if you as an individual have the natural ability, the hard work, the intellect and the insight to take up opportunities. But a second element is being in an environment that fosters that ability — that allows you to grow, whether into a world-leading clinician, or into business, or any other element of life. You really need that environment to develop as an individual, clinically and professionally. So those are two very important elements: the natural ability, insight, talent and hard work — and being in the right environment.

That was a big part of my decision-making when I was thinking about where I really wanted to go. I had enough self-confidence to believe I had some natural hard work and intellect inside me. But whether I was in the right environment — and which was the right environment for me to be in — was the question.

Answering more specifically: it's an institution that really does allow one to grow and take up so many opportunities, because it's well run with that specific objective. That was somewhat lacking where I was previously, and that felt like a lot of my decision-making about going to Mayo.

I'm going to answer that in terms of training, in residency, rather than practising. There were probably six reasons why I decided in the end to train in the US. One was the emphasis on education, and the value placed on it. As a resident you get dedicated time — 30 to 40 minutes in the morning, an hour in the afternoon — and incredible teaching from great clinician-educators throughout the day, developing your clinical judgment. Compared to where I was in the UK, it was more learning on your own — one hour a week of Thursday-afternoon teaching as a junior doctor. And it's such a busy service in the UK that you don't have the time or luxury to read around topics and share research studies. That was one element.

Two was research opportunities: both access to cutting-edge research, because of the funding of a lot of US institutions, and their ability to engage younger residents in it. From what I saw — and this is an n-equals-one study — a lot of trainees in the UK had to pursue PhDs to get any meaningful research done, because they didn't have the time, and the training environment wasn't set up to let you take a month off a year to focus on research.

Number three — and this is subjective, from my experience — is this notion of a glass ceiling in the UK. I saw a lot of very bright surgical and medical registrars at ST7, ST8 levels still floating around, trying to get a consultant job because none was available. And being able to get into a top teaching hospital in London meant so many other things — it wasn't just about your hard work, your publications, your CV; it was so many other factors. Compare that to seeing residents and fellows finishing fellowship in the US and their career progression — joining academic staff, going into associate professorships, professorships, that track. Grossly subjectively, I just saw it was so much more doable, if that's a word. That fed into my decision-making: if you want to become a world-leading clinician, it's very much doable — you obviously have to go through the hoops, but there was an element of meritocracy being rewarded more so than I felt in the UK. But that is so grossly subjective, so I may get a bit of stick for it.

And then, a big factor for me was the culture. To give a grossly subjective example: as a junior doctor in the UK, what's the culture like between you and a professor in your field? Say you've got a difficult case — are you in a position to pick up the phone and call the consultant for input and advice? A lot of the time, even ordering scans, you'd get nasty feedback when you picked up the phone to order an MRI or a CT — you'd have consultants saying, "I don't speak to junior doctors below med regs; I only speak to regs or above." That psychologically impacted me a lot.

Compare that to when I moved to the US, where you have world-leading clinicians taking the time not just to give you an answer, but to explain the rationale — why you should be pursuing this line of thought, why you're ordering this — giving you that education in real time. That culture is what really sold it to me.

My views are always going to be through the lens of working at an institution like Mayo, which prides itself on an environment of teaching, research and delivering clinical care — those are what the three shields mean. So a lot of emphasis is placed on valuing physicians as human beings, and you really do see the shift in emphasis by program leadership towards prioritising physician and resident welfare.

That said, you touch on an important point I've seen too. The working environment is very different to the UK, and the reason is simple: in the UK you have a National Health Service, which at the end of the day is a government entity, and working for the government is very different from working in the private sector. In a government entity you're a small fish in a large employment sector — the NHS is the single largest employer in the UK, I'm pretty sure that's correct. In that environment there's a lack of ways to distinguish people who do really hard, high-quality work from those who are floating along doing the bare minimum.

That's something that annoyed me. As a junior doctor you'd come across incredible physicians going above and beyond, delivering great care, and then compare them to folks coming in late doing the bare minimum — and at the end of the day both progress at the same stage and get similar jobs. That influenced my thinking: where's the reward for putting in so much hard work? That feeds into what type of healthcare system you're in. In a government entity, the emphasis is less on rewarding hard work — but the benefit is you're in a lower-stress environment when it comes to proving yourself at work.

In the US, I'll speak generally: as a resident or medical student you're always out to prove yourself to get to the next stage, because the amount of work, research and dedication you show really influences what fellowship you get, whether you get strong or average letters of recommendation, what board scores you get — all of that well and truly influences your future career. So the difference in stress at work is the key answer: in the US you're always out to prove yourself, because by proving yourself you do get rewarded — being taken on as staff, being promoted from associate to full professor.

There's an element of that in the UK, but much less so. As an F1 you just need to get your job signed off, attend a few meetings with your clinical supervisor, don't get into too much trouble, and then apply for CMT, tick a few boxes — how many audits have you done, and so on. I hope that answers the question.

It's very easy to tell them exactly what the process is: you do this, then the exams, when's the right time to do the exams, how you go about getting a residency post, what you do at interview. Those are all somewhat easy to answer. What I always start with is answering the question "why" — why do I want to move to the US?

The reason I say that is that the whole process is very difficult. It's costly, it's hard work, and it's long. You will come across times when you're asking yourself, why am I even doing this, it's so much work, is it even worth it? And if you don't have a good answer to the "why", it's going to be very difficult to push yourself through — when you're studying all those extra hours, coming back from a clinical placement at 5 or 6pm, doing thousands of UWorld questions, getting only 20 or 30 percent right and thinking, I can't do this, it's too difficult. If you don't have a good answer to the why question, you're going to struggle. That's my honest opinion.

For me, the why was some of what I said earlier: education and the focus on it, research, the glass ceiling, the meritocracy of US career progression, and the culture of Mayo in particular — I was always set on Mayo for separate reasons. All those reasons gave me strength in the difficult times.

It's not enough to say physicians in the US make X and physicians in the UK make Y, so I want to go to the US. If money is purely your reasoning, there are many easier ways to make money — I say this to them, it's so much easier to make money in other fields, and I don't think that's a good enough reason. If the reason is "I want an adventure", there are so many other ways to have an adventure. It's true to say you want an element of adventure, an element of being comfortable in your life, or that you're sick and tired of the UK — all valid — but be clear and true to yourself on why you want to go.

My philosophy has always been fed by what my parents always used to tell me — a phrase in my own language, Urdu, that I'll translate as best as I can: in every decision you make, there is always a blessing of your creator, if you have the right intentions.

It's a very deep point, so let me expand. If you have the right attitude — whether applying for posts, or doing well on exams — and you come in saying, I'm going to put in a lot of hard work and then I'm content and happy with whatever happens; if I get it, there's a blessing in that and it was meant to be, and I'll accept it and move on. And more importantly: you put in the real hard work, you study night and day for an exam or an application, and you don't get that post — there is a blessing in that as well. Having that mindset — that maybe it wasn't meant for me, as much as I wanted it, as much as I thought it was the right decision — there is a higher purpose, a blessing in disguise you won't appreciate at that specific point in time. That belief really changes the way one approaches decision-making.

A very personal story: when I was applying for medical school, I was really set on going to Cambridge or Oxford. I'd put in all the hard work, and at 17, 18, I didn't get it. I was so distraught, thinking, this is a calamity, I've been cheated, I deserved it. Now, looking back seven or eight years, there was so much blessing in that. Being in a different environment — in London — allowed me to meet so many different people and to be the person I am today. I wouldn't be here in the US if it wasn't for that decision, right then and there, when I was so distraught.

Moving forward — how do I approach applying for a position, or even for residency? It's a very stressful time. As an international graduate there's no guarantee: on paper you may be stronger than a lot of other applicants, but because you're an international graduate with the wrong visa, you're not going to get interviews that other people will. How do you approach that? My philosophy was always: I put in the hard work, I have no regrets about the work I put in. The decision — if it happens, it happens; if I don't get it, I don't get it. There's a blessing in every decision.

That's allowed me to deal with failure — which touches on something you referred to earlier. It's very easy to learn how to win. I relay this back to when I was 14, 15 and at one point wanted to be a pro tennis player. If you win a tennis match — great, you won, good for you, you move on to the next. But you lose that match — how do you deal with that failure? How do you deal with not getting into an academic position you wanted, or not getting into medical school the first time around, or not getting the job you wanted? Learning how to fail, and how to approach failure, really shapes your career.

Are you someone who gets so distraught and demoralised that you give up? Or are you someone who takes stock and says, I put in the hard work, it didn't happen because of X, Y and Z, I'm learning from X, Y and Z, there was also an element of luck — but regardless, I'm content, I'm going to move on and try again. Having that mentality of accepting failure when and if it comes, learning from it, and then not giving up — that really does shape your whole career. It's something I'm continuously trying to learn as well.

You'll have noticed all my answers are very general — I naturally tend not to like talking about myself in specifics. But, very specifically: for me it's a lot of faith. I have a strong belief in God, and that feeds my everyday routine. Engaging in prayer, clearing my conscience, supplicating — I find that gives me strength every day. Everyone has their own way of seeking contentment and peace, whether that's yoga, prayer, exercise, playing an instrument, whatever it is. It's very important that you find what brings you peace in your life. For me it's prayer, and that gives me the ability to carry out my day with a clear conscience.

Number two — on this element of grinding — is the power of email. My dad always used to say that every day you should be sending out five to ten emails. If that's all you do in your life, get five or ten emails out a day — even on your day off. What does that mean? People you're working with, people you want to work with, colleagues, mentors from afar or close — emailing them to get your name out there, to show your activities, to engage and network. On my front, that means engaging with my mentors and colleagues to keep in the loop — more so in the business environment than in medicine. I remember at McKinsey it was about emailing the project manager and everyone in the team, not just about work but catching up with them and growing your network.

Number three, on habits, is the importance of reading and seeking knowledge. There are so many ways to seek knowledge now. In the olden times it was about reading a book in the library; nowadays you can acquire so much just sitting in your room — YouTube videos, podcasts, chat rooms like Clubhouse, which I was on a couple of days ago — acquiring knowledge in small tidbits through the day. For me it's a lot of YouTube: I listen to a lot of videos about people I aspire to, whose mentality and way of thinking I love, and that really feeds my soul.