Monday, 30 January 2012

Peter Rothwell: A Stratospheric Rise to a Giant of Neurology

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The Lancet, Volume 377, Issue 9778, Page 1645, 14 May 2011
doi:10.1016/S0140-6736(11)60662-4Cite or Link Using DOI

Peter Rothwell: a dedicated flouter of fashion

Peter Rothwell, 1980—90: a lack of direction and an undistinguished career as a medical student. Peter Rothwell, 1991—2011: award-winning Director of the Stroke Prevention Research Unit at the University of Oxford, UK, and author of over 300 publications that have transformed the landscape of stroke prevention. He is a man who takes some figuring out. Reflecting on Rothwell's stratospheric rise to a giant of neurology, Charles Warlow, Rothwell's mentor and Professor of Medical Neurology at Edinburgh University, says simply, “he's a phenomenon”.
The past two decades have seen Rothwell show which patients benefit from carotid endarterectomy to prevent stroke, that there is a high risk of major stroke after transient ischaemic attack (TIA) and minor stroke, and that there are enormous benefits from urgent treatment to reduce this risk. This work called for greater urgency in investigating and treating minor stroke and TIA, which had previously been thought of as fairly benign conditions, so Rothwell developed a risk scoring system to enable clinicians to predict the likelihood of stroke in the first few days after TIA.
More recently, Rothwell has found that variability in blood pressure is at least as important as mean blood pressure for predicting the risk of stroke and that some of the most effective antihypertensive drugs reduce variability, as opposed to simply reducing mean blood pressure. Along the way, he has proved that the statistical basis of the “usual blood pressure hypothesis” approach to diagnosis and treatment of hypertension is invalid, and has still found time to show that aspirin can reduce mortality due to several major cancers.
Rothwell's record is extraordinary by any measure, but juxtaposed with his early years as a medical student it almost defies belief. Born to a 16-year-old single mother in a poor area of Liverpool and adopted and brought up by a family in Manchester, Rothwell got good grades at school. But, as the first person from his family to go to university, he had little sense of what kind of career he wanted. “I didn't have sufficient knowledge or originality to think of anything else to do, so I did medicine”, he says. Rothwell ended up at Edinburgh University, where he cheerfully admits to not being “particularly academic”. Far more interested in indulging his passion for mountaineering than attending medical lectures, “he was completely obscure as a student”, says Warlow. “And he became even more obscure when he went off to do his senior house officer [SHO] jobs in Middlesbrough.”
It was during his time working at the intensive therapy unit in Middlesbrough that Rothwell gathered data, largely unsupervised, on the endocrine response to critical illness, which he then wrote up for his MD. “That was extraordinary”, says Warlow. “I mean, no SHO collects data for an MD. Somehow or other, Pete just did it. And it's been just like that ever since. He just gets on and does it, and he does it at the most extraordinary speed.” A move back to Edinburgh as a clinical research fellow, and into Warlow's tutelage followed. “He got me interested in stroke and was an inspirational supervisor”, he says of Warlow. “And stroke has been my main focus since then”. His time with Warlow also laid the foundations for Rothwell's appreciation of the importance of asking the simple questions about how to best do medicine in the real world, and gave him the confidence to challenge the consensus. Louise Silver, Research Co-ordinator at the Stroke Prevention Research Unit, Oxford, which Rothwell established in 2000, explains that these are virtues that he is passing on to his own fellows. “His focus on clinical research, and how this can directly impact patient care, certainly gives myself and others a feeling that all our hard work has and will make a difference”, she says.
In an age when so many researchers fall over themselves to jump on the latest bandwagon, Rothwell is something of an iconoclast. “Medical research is so fashion conscious”, he says. “Everyone suddenly becomes geneticists, then 10 years later they're stem cell researchers.” By contrast, Rothwell's willingness to eschew fads has helped him reap a bumper crop of what he calls, for want of a better term, low-hanging fruit. “There's so much simple clinical research that should have been done 50 years ago but wasn't”, he explains. “The work we've done on working out the prognosis of TIAs and minor stroke should have been done years ago but wasn't.” The same can be said of his work on blood pressure variability and risk of stroke or the non-vascular effects of aspirin. “It's all simple stuff”, he insists.
For someone whose work has garnered such acclaim, Rothwell's modesty is striking. But beneath the softly spoken self-effacement, you get a sense of the kind of strength of character that has helped propel him so far, so fast. Moving to Oxford having been an undergraduate elsewhere certainly requires mental fortitude, and despite “still feeling like a new boy”, he has flourished. “He's quite tough you know, Pete”, Warlow attests. Still only 47, Rothwell is showing no signs of slowing down, and wants to carry on the Oxford Vascular Study, which he established in 2002, for another 20 years “to really understand what's happening to vascular disease over time”. He also expects variability in blood pressure to come further to the fore, especially in relation to dementia. And he hints that aspirin (he takes it) might still have a few new tricks up its sleeve. Considering what he has achieved in the past 20 years, the possibilities for the next 20 seem endless.

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