11 April 2022

The Crucible Prize is an innovative trainee-led initiative with a £1000 prize. The theme for 2022 award was ‘What current haematology practices would seem absurd to the haematology community in 2050'.

The five best abstracts were selected for oral presentation at the 62nd Annual Scientific which was held on 3-5 April 2022. We are pleased to announce the 2022 winner was Richard Buka. Richard presented on the topic of ' 2050: A year of re-enlightenment’

We interviewed Dr Buka to learn more about his journey in haematology and his Crucible Prize success.

What is your education/career background in haematology?

I attended medical school in Birmingham and then went into the academic foundation programme in Stoke-on-Trent. After a bit of traveling, I then started an academic clinical fellowship in haematology in Birmingham. After a couple of failed attempts to get PhD funding later, I changed tack a little and I finally went out of programme in February to start a PhD looking at thromboinflammatory effects of DOAC reversal at the University of Birmingham.  

What was your Crucible session presentation about?

My talk was entitled "2050: A year of re-enlightenment." When I saw this year's question, my mind immediately sprang all over the place, but I thought rather than going for a more obvious idea, I would gamble, take more of a risk, and try to be quite provocative. In the talk, I reflected on how medicine has often harmed patients as we have based treatment on theory rather than proper evidence. 

This is something that I think is caused by a few things. Firstly, there is the admirable desire to help our patients by doing something. The history of medicine is full of examples where patients have been harmed by this. As humans, we naturally see the world through our own lived experiences. Some medical practices are supported by a beautiful narrative and are advocated for by physicians who have used these practices and have seen patients get better. It is very hard to argue in one’s own head against this, but the fact of the matter is that this way of thinking is frequently wrong, and when entrenched medical practices based on these very principles are properly assessed for safety and efficacy, they are frequently found to be either ineffectual or even harmful.   

Critical to the talk is my belief that the most important medical advance of the last century is the randomised controlled trial. It's amazing that it took so long for humans to invent the randomised trial, which seems so very obvious to us now. The first proper randomised trial was performed in 1948, some 300,000 years after homo sapiens first emerged. I think that the principle reason for this is, as I have said above, is that we humans love a story, we want to believe our own eyes, and we are biased toward the benefits of action over inaction. 

Trials are often the real bottleneck in getting drugs into the clinic, so we have developed what we think are clever ways of speeding this up with the ultimate goal of selling a drug. Unfortunately, many of these methods mean that trial results don't give us the truth that we need. For example, trial endpoints often do not focus on what is really meaningful to patients - improving quality of life or lengthening life. To try and get drugs through the pipeline quicker and more easily, there is widespread use of poorly validated surrogate endpoints like progression-free survival, or changes in laboratory values. These often poorly correlate or do not correlate at all with outcomes that are meaningful to patients. All this means is that drugs are approved that have activity but often don't improve patient outcomes.  

There are risks of not acquiring randomised trial evidence before doing things to patients. One example is accelerated drug approval which can often push unproven therapies into public use before there is good evidence - again a policy that is, at least in part due to our desire to do something rather than nothing.   

My entry ends on a positive note. The good news is that we do not need a revolution in thinking. Humans have already taken a huge leap forward in recognising the importance of the randomised trial and what it can give us: truth. But, we need to change our systems so that our enhanced command of nature can be fully harnessed to more efficiently benefit humanity. 

What inspired the content of your presentation?

My PhD will focus on the clinical use of reversal agents for DOACs in the UK as well as some basic science work around DOAC reversal. Whilst planning the project, I became a little obsessed with the lack of randomised trial evidence for DOAC reversal. Many will think of administration of a reversal agent when someone is bleeding as something that can only be a good thing. The narrative is compelling: 'patient on blood thinner, patient bleeding, must switch off blood thinner'. It makes sense, doesn't it? The argument is logical, but it fails to recognise the lessons of history where sound, rationale arguments used to guide therapy have often been proven wrong. The body is very complex and our current understanding is not good enough to assume we can predict the success of a therapy without empirically testing it. Having had this revelation, I realised there was a whole world of medical literature, books, podcasts, and tweets on the subject so I've been hoovering up this information for the last couple of years. 

What does winning this award mean to you?

Firstly, it was an immense privilege to share the Crucible stage with some incredible colleagues. The other talks were novel, insightful, and exceptionally well delivered. I can't imagine that judging them and picking a winner was an easy job! The most important thing about this opportunity is the opportunity to share an idea that is, I feel, being talked about more and more. It's really important that we address the important issue of quality of evidence in medicine and the more people that know about the problems, the better. 

What would your advice be for someone wanting to choose haematology as their specialism?

Haematology is a fantastic, diverse speciality. Although when you start haematology, you will be at the start of specialising, you will soon realise that there are so many things you can specialise in that you will never be bored. My advice would be to have a couple of taster days but don't just do the obvious thing like going on ward rounds and lymphoma clinic. Go to a bit of MDT, go to the obstetric haematology clinic, sit in on the hospital transfusion committee, and get someone to show you around the lab. There are so many opportunities!

Haematology can also offer a lot of academic opportunities too but to see a good project through from start to finish takes time. So, my advice is to, as early as you can, get involved in a few projects - it doesn't have to be haematology - it's all about research skills. For haematology projects, I would encourage people to get involved with HaemSTAR which is the UK-wide network for haematology trainees interested in non-neoplastic haematology research. Finally, I would recommend that you read and listen widely. Some recommendations for podcasts are 'Blooducation', 'Plenary Session', 'Bedside Rounds', 'Blood Bank Guy' and my own 'Don't Just Read the Guidelines'

What do you plan to do next in your haematology career?

I'm now captive on a PhD programme until 2025 so the plan is to work hard on several projects, grow my podcast, and help to grow HaemSTAR. Ultimately, my goal will be an academic haematologist running clinical trials. 

Dr Buka donated his prize money to the Sickle Cell and Thalassaemia Unit, Birmingham City Hospital, Sandwell and West Birmingham Hospitals NHS Trust. If you would like to donate to the Sickle Cell Society follow this link: https://www.sicklecellsociety.org/supportgroups/

Images by Simon Callaghan Photography: https://www.simoncallaghanphotography.com/