The Big Interview – Professor Ketan Dhatariya
Professor Ketan Dhatariya started his diabetes career on the Isle of Wight, before continuing with a succession of registrar jobs in South East London between 1997 and 2001.
He finished his training in diabetes and endocrinology in 2001, but instead of taking up a consultant post in Dartford in Kent, he opted to give it all up and go and do research in America.
Returning to the UK in 2003, he worked as a locum consultant at King’s College Hospital. Now he has several national roles in the UK which are all based around different aspects of diabetes.
How did you get into diabetes?
I wasn’t particularly interested in diabetes when I was a junior doctor. I had done my Senior House Office (SHO) jobs and got my exams, and then had no job to go to.
I saw an advert in the BMJ for a two-week locum in diabetes on the Isle of Wight. I said to myself; “two weeks in the summer on the Isle of Wight, why not?”
My boss there, Arun Baksi, made me sit with him in his clinic for three days and taught me what I should be doing and then let me loose. Within a few days he told me this was the job for me.
Because I was a locum on the Island and had no intention of doing diabetes, Dr Baksi suggested I stay put until I did find a job that suited me.
Over the next 12 months I applied for almost 125 jobs in several different specialities and was only shortlisted once – and even then I didn’t get the job.
Eventually, I was asked to leave (too expensive). I was then a locum Senior Resident (SR) in geriatrics in London for three months and was then completely unemployed for another three months during which time I’d also failed to get a job with two pharmaceutical companies (I failed their personality tests).
Then a job came up in diabetes in South Thames as a lecturer. I thought to myself: “I’ve done diabetes, I’ve been an SR, I can do that.”
I was called for an interview and told me I didn’t get the lecturer post but introduced ‘this new thing called a number’.
And it went from there. I am forever grateful to Arun Baksi.
What’s been your biggest achievement in diabetes?
There are several things that I am proud to have achieved. Firstly, being recognised for the work myself and others have done for inpatients with diabetes as part of JBDS since it started. Now I’ve been handed the responsibility of being Chair, which is something that I am extremely proud of. To know that my peers and colleagues feel that I have the ability to carry on the phenomenal work of Mike Sampson is very humbling.
Also, getting a PhD in inpatient diabetes was special, along with being named as the Chair of the Specialist Clinical Exam in Diabetes and Endocrinology in the UK and to then be asked to be the Chair of the Exam Board for the European exam is also something that I never imagined. However, when the time came I was very honoured to be asked to take over that post. I’m also really pleased that I made my father proud by becoming a professor of medicine.
Tell us about your experience at the Mayo Clinic in Minnesota where you carried out research after completing your diabetes training in 2001?
My experience in the Mayo Clinic in Minnesota came around by serendipity. I was very interested in intensive care when I was a trainee in diabetes and endocrinology and in my penultimate year of training I was put in touch with a lady called Margot Umpleby at St. Thomas’. She was an expert in skeletal muscle protein metabolism. She felt that this could be looked into more in the world of intensive care and she helped me put together an MD project.
We worked on a project to look at outcomes of insulin and glucose control on ITU patients – which unfortunately was never funded. I was pleased to see that our idea had already been thought of and that glucose control on ITU made a difference to outcomes. However, one name that kept cropping up in my research was Sree Nair, and in my naivety, I emailed Professor Nair at the Mayo Clinic and asked him to have a look at my protocol to ask him why it wasn’t getting funding. Cheekily I sent him a copy of my CV and also asked whether he had a job going at the time too.
Unbelievably, the next day he called me at home and offered me a job! Even though I was very close to the end of my training, and had a job offer as a consultant in the UK, I chose to go to the US for two years.
At the Mayo, under the inspirational mentorship of Sree, I did research into skeletal muscle protein metabolism in hypoadrenal women and did a randomised trial giving them dehydroepiandrosterone (DHEA). But I also got the chance to work on other studies looking at DHEA in the elderly, as well as looking at mitochondrial protein turnover in insulin deprivation in people with type 1 diabetes.
I was in contact with some of the world’s leading minds in the world of diabetes and endocrinology. I also got to meet and hear several of the world’s best people talking at the Endocrine Grand Rounds at Mayo. When Mayo asks people to come and speak, very few people turn them down!
In August 2019, we reported on your ranking of fourth in the world for your research into DKA on leading index Expertscape. Why and how have you become such a leading figure in DKA research?
Yes, that came as a very big shock! I fell into diabetic ketoacidosis almost by mistake.
As a newly appointed consultant I was challenged by an anesthetist who asked me why diabetes doctors insist on using normal saline as a resuscitation fluid in DKA?
My initial answer was basically because it had always been done that way. But it got me thinking, and I got into the subject in more detail and that led to me writing an editorial that was published in the BMJ.
This was at the time when the JBDS was just starting to write their guideline on DKA and as a result of the editorial, I was invited onto the writing group.
Mark Savage had led the writing group for the first edition but he left to go to Australia and when it was time to update the guideline it was handed to me. I then decided to see whether the guideline worked and did the National Survey in 2014, subsequently publishing a lot on DKA.
It’s always a surprise to me that the management of a reasonably common condition has so little evidence behind it. I’ve been very fortunate to know the others who are above me on the list who are all well-known academics. So, as a full time NHS jobbing doctor doing at least six clinics a week, to be among them is really special.
Your predominant areas of interest are inpatient diabetes and the ‘diabetic foot’, tell us about your work in these areas?
Until relatively recently inpatient diabetes was a neglected subject. In my work on the steering group of JBDS, and as one of the co-authors on many of the guidelines, it is just something that has evolved. As a group we’ve tapped into an area of unmet needs and probably one of the reasons that the guidelines have been taken up so rapidly and enthusiastically.
I think this is largely because the management of inpatient diabetes has – for the most part – been an evidence-free zone. Because of that the guidelines are largely consensus-based, but they have still been welcomed by diabetes teams who don’t have to then start creating their own guidelines from scratch.
When it comes to feet, when I was a registrar I was very lucky to work at King’s under the mentorship of Mike Edmonds and his lead podiatrist Ali Foster.
The diabetic foot interested me from the very beginning and I spent several months of my time at King’s in the foot clinic. When I came to Norwich I realised that my podiatry team were full of enthusiasm which I was able to tap into and encourage.
The foot team I’m part of are as interested in research as I am and we draft in large numbers of medical students and junior doctors each year to do all the hard work. I’m then responsible for crafting the end product.
Foot disease is, again, a relatively small area which is in need of more evidence, so we help to collect that and have been invited to take part in several trials.
Within the foot team we are a “mutual admiration society” trying to encourage each other to do the best for people with foot disease. I’m really pleased for my principal podiatrist Catherine Gooday who is currently doing an NIHR fellowship for her PhD as well as being part of NICE and NDFA and other national bodies.
In the summer you became chair of the Joint British Diabetes Societies Inpatient Care Group, what are your plans for the organisation?
My plans as chair of JBDS are that I want to start refreshing all of the guidelines. Many of them are quite old and part of my remit is to try and ensure that they are kept up-to-date.
Ideally, we would have liked to get some money together for a junior doctor or a JBDS fellow to do much of the work, but given that the NHS is in such dire financial straits, it has proven difficult to raise any money. If anyone reading this has any bright ideas then please get in touch!
However, we have recently worked with the Department of Service Design and Innovation at the Royal College of Art to help redesign the website. Also, we’ve been looking at how to make the guidelines more accessible on all platforms, including mobiles, and the internet. Hopefully, we will be able to get to the relevant parts of the guidelines without having to click through several pages.
We also want to incorporate more users on to the group. We have recently recruited twi junior doctors and we are working with our parent organisations, ABCD, DUK and the Diabetes Inpatient Specialist Nurse group looking into recruiting members of the lay public to help. It is a work in progress so watch this space.
You are the Chair of the Examination Board for the Specialist Clinical Exam in Diabetes and Endocrinology, describe any changes to the exam over the last five years.
The main change over the last few years is the development of the new European Board Exam in Metabolism, Diabetes and Endocrinology which is run under the auspices of the European Union of Medical Specialists (UEMS) and the European Society for Endocrinology. As the Chair I have tried extremely hard to ensure that the Specialty Certificate Examinations (SCE) and the European Board Exam are identical so that candidates have to reach the same standards.
As a group, we have been successful because the two diets that have been run to date have been identical. They have had identical pass marks for both exams. It has been quite fraught at times and it remains to be seen whether the pilot for the European exam will continue in the same format and with the same exam as the UK SCE.
It has been a real pleasure and privilege to be part of the exam and, indeed, having been part of the UK exam since its inception, sitting around with the UK leaders of all aspects of diabetes and endocrinology has been the best CPD I could ever have hoped for because it allows me to ask questions of the best and hopefully I don’t come across as too ignorant!
You are on the council of the diabetes and the endocrine section of the Royal Society of Medicine (RSM), tell us about this role and what you have been working on?
I am currently the President of the section of Diabetes and Endocrinology at the Royal Society of Medicine. The RSM is really
I am currently the President of the section of Diabetes and Endocrinology at the Royal Society of Medicine (RSM). The RSM is really an educational organisation and part of my role previously was as the secretary of the section.
Now as the President of the section my role is about looking to organise meetings that are both interesting, informative and relevant to various audiences.
In April 2020 we have a fantastic meeting looking at kidneys, heart and diabetes with some of the countries experts on these conditions speaking.
In June we are putting together a day about the diabetes and endocrine eye. Looking into 2021, we will put on a programme looking at the genetics of diabetes and endocrinology.
Going to the RSM and looking through the register of people who have been on the council, it is a whose who over the last 50-60 years of the top names in the world of diabetes and endocrinology and to be a part of that is a real thrill for me.
You have had more than over 120 peer-reviewed publications and published several book chapters on inpatient diabetes and others on the diabetic foot, which one has had the biggest impact?
I have been involved with had several publications, but to say which one has had the biggest impact is a very difficult question.
The one that has been cited the most is the one that was in the New England Journal of Medicine from my time at the Mayo Clinic. However, I was only fourth author on that paper. The first author was the man who received the grant from the National Institutes of Health (NIH) and also my boss Sree Nair. Second author was the then President of the American Diabetes Association and the third author was a statistician who had statistical methods named after him. Then there was me, followed by many people. So that remains the most cited paper on which my name appears.
My very first publication was anonymous and was published in the BMJ in 1997 as a Personal View and it was called ‘I don’t have prizes and publications’. It recounted the difficulties I had when I was a junior doctor, being told I was not worthy of pursuing a career in hospital medicine because of the colour of my skin. It was those experiences, such as one famous consultant – not in diabetes I hasten to add – putting the phone down on me when I was looking for a job telling me that they were only looking for “high flyers”.
But which paper has had the biggest impact? No idea. I’d like to think all of them!
Talk us through a typical day in your professional life?
If I get to work by 7:15am I think I am late, luckily I only live 10 minutes from work. Most of my working week is in clinics as I do six or seven a week. The rest of my time is devoted to normal stuff such as administration, going to various meetings within the departmental or multidisciplinary teams (MDT’s).
It’s only if I find time at lunchtimes, or before or after work, that I get to do all of my other extracurricular work for JBDS, the Royal College of Physicians, or writing or reviewing papers.
I am lucky to have been invited to be an associate editor of Diabetic Medicine and BMJ Open Diabetes Research and Care, which also takes up time.
If I leave work before 6pm, then I feel I’m leaving early. As with many of my colleagues, work doesn’t stop when you leave the building, it usually spills into the evenings and weekends.
To say I have got my work/life balance wrong is something that my family will tell you all of the time! Luckily I have an understanding wife (without whom none of this would have been possible!)
What projects are you currently working on?
I have just finished a couple of reviews for publication, one on DKA and another on inpatient diabetes. More recently I have been interested in glycaemic variability and outcomes in people with diabetes. I’ve have had some medical students working on glycaemic variability and outcomes in cataract surgery, and others looking at how it affects the development of retinopathy.
I am also involved in some research trials for some pharmaceutical companies and I am the National Lead for Endocrinology for the FOCUS Study, looking at the effect of subcutaneous semaglutide on the development of diabetes-related eye disease.
In addition, I am also the local principle investigator for a number of other studies. I’m on the clinical adjudication committee for some trials, and am chairing trial steering committees of a couple more.
Later this year I have been asked to give presentations at Diabetes UK on inpatient diabetes and at the Malvern Foot Conference.
I’ve also been invited to America to speak on peri-operative diabetes care at the Diabetes Limb Salvage Conference in Washington DC.
I’m helping to supervise two PhD’s and have also worked with a group looking at the impact of maintaining or improving glycaemic control on CO2 emissions.
Then there is the work for the International Working Group on the Diabetic Foot which has just finished its review and guidance on wound healing interventions.
There is also a very interesting project looking to see if having diabetes protects against developing giant cell arteritis. Another fascinating area I’m just starting is using the UK biobank to see if per-operative outcomes can be related to genes.
Another is looking at skin proteins in foot wounds in people with diabetes. There is a lot more, but of course, the day-to-day stuff with clinics also keeps me busy!
What is the future of diabetes care in the UK?
I think the future of diabetes care in the UK is very rosy. The combination of increasing awareness of diabetes as a major public health issue and the complications that cost so much, will definitely continue to play a big part in the future of diabetes.
In addition, the work being done by people such as Jonathan Valabhji, Partha Kar and Gerry Rayman, have highlighted where things need to change or be done differently.
I was fortunate enough to be part of Mike Sampson’s Norfolk Diabetes Prevention Study and I think that will change what we do as a nation in terms of a public health approach.
JBDS working with the Care Quality Commission (CQC) means that hospitals have to pay greater attention to the care of people with diabetes in hospital to ensure that they get a reasonable rating.
Also, working with Daniel Flanagan from Plymouth, Gerry and the team at Diabetes UK to come up with a way of accrediting inpatient diabetes services is also going to lead to improved care. As will everything, because we all have day jobs, things take time, but we want to do things in the right way at the right time because we understand the implications of not doing this properly.
What do you do in your spare time?
What spare time? I love to watch films. I’ve seen one every six days or so during 2019, which is the lowest number for a decade. Apart from that, just trying to keep the family happy.