Interview with Professor Joanna Wardlaw: ‘I enjoy challenging dogma’

(Photograph: Maverick Photo Agency)


Four students from the MSc Translational Neuroscience courses interviewed Professor Joanna Wardlaw, Chair of Applied Neuroimaging and Head of Neuroimaging Sciences and Edinburgh Imaging. She is a Fellow of the Academy of Medical Sciences and of the Royal Society of Edinburgh. In 2016, she was appointed a Commander of the Order of the British Empire ‘for services to neuroimaging and clinical science’. Among the many prizes, she was awarded the President’s Medal of the British Society of Neuroradiologists and the Karolinska Stroke Award for Lifetime Contribution to Excellence in Advancing Knowledge in Stroke.

The questions were created by Valeria Finelli, Hamida Mussa, Sasha Pokrovskaya and Rowida Tarabzooni.


Out of your countless publications, which paper did you have low expectations for or adopted as a side project but became more impactful in your life or career than you first assumed?

Tricky question. Probably a paper on clinical outcomes three years after a minor stroke. It was a secondary paper from a relatively small single-centre study (McHutchison et al. JNNP 2019). However, it generated a huge response on Altimetric (which tracks social media response to scientific publications), being in the 98th percentile four weeks after publication and in the top 5% of all 12,519,686 research outputs ever tracked by Altimetric at that point. It appears to have ‘touched a nerve’ amongst patients since it reported that 44% had cognitive impairment, 39% had depression despite being classed as ‘mild’ at the time of the stroke, and only 12% were dependent. It led to studies on what aspects of minor stroke and small vessel disease are important to patients, to more intensive studies to understand why cognition and mood were so affected, and now to find ways to improve clinical services for patients with lacunar stroke (a common cause of minor stroke) and other presentations of Small Vessel Disease (SVD).


Why did you choose to get into research after your Medical Degree?

Most medical knowledge is only partial, with many more unanswered questions. The more you uncover, the more questions are raised. I wanted to answer those questions and find better ways of improving outcomes after stroke. I enjoy challenging dogma, of which there is a lot in medicine, and other scientific fields, particularly when it has little evidence base and may be harmful. There are many examples in medicine where accepted wisdom has proved to be wildly wrong and, not infrequently, the opposite turns out to be true.


When inspired to specialise in your field, how did you choose to go into small vessel diseases? Was it an easy choice?

I started my research originally into large artery ischaemic stroke because I was interested in thrombolysis. Later, I observed some features of a small lacunar stroke that did not fit with the accepted wisdom about causes, started reading and realised that there was a lot more going on in the brain and that lacunar stroke was only one sign of diffuse disease. My interest in MRI meant that it was possible to use Magnetic Resonance Imaging (MRI) as a sort of modern in vivo microscope to see what was going on in the brain at the microvessel and tissue level, and it all went from there.


Which public engagement activity do you enjoy doing?

I enjoy seeing patients, which I do on a weekly basis through my clinical work. I also enjoy having patient representatives on study steering committees and getting their input on study design. I also have enjoyed giving public lectures since the public asks the most probing questions.


What refinements need to be done for a timely diagnosis of strokes and the future of rehabilitation?

There could be a better application of the knowledge that we already have and avoid wasting time on procedures that sound like they might be helpful but in practice are not. Getting a rapid plain Computerised Tomography (CT) or MRI scan is critical; with MRI, you have to use the correct sequences, or it is a waste of time and money (too many places still omit a blood-sensitive sequence). CT angiography or MR angiography may be helpful if a large artery occlusion or dissection is suspected. Still, perfusion imaging is not helpful in the 1st 5 hours (it just adds to delays). After 5 hours or in patients with an unknown time of onset, then perfusion imaging may be helpful, but only then. There is a lot of pressure to use Artificial Intelligence (AI) diagnostic scan reading tools, but none of these is reliable yet, miss haemorrhage and (like perfusion imaging) just waste time. AI tools can only be used by experts, but experts already know what they are looking at on the scans, so what is the point? Maybe one day the AI tools will be useful, but, at the moment, they are not very helpful and even potentially misleading.


What do you love about Edinburgh University, and what about the institution influenced you to stay with them for so long?

Hmm. Edinburgh is a beautiful city with many things to do and wonderful countryside. I work in both the University and the NHS, and both organisations have many good but also sadly bad points! I have, in the end, remained here because I have spent a lot of time setting up large imaging and other research facilities and built collaborations that I need to do my research – I have considered moving on many occasions but realised that it would take several years to get back to where I had been in Edinburgh which would seriously delay the research, so have remained here despite numerous downsides to aspects of the way in which the University functions. I have many external collaborations, which mean that I am not really just working at the University but with many networks of great people all over the place.


How did stroke diagnostics change during your illustrious career, and how do you see it progress in the next 25 years?

Some of this is answered above. Advances in CT like faster scanning, angiography and perfusion imaging have advanced enormously in the last 30 years. MRI has also changed beyond recognition. Some of this has filtered through into the clinic. In the end, the practical things with obvious benefits tend to stick, while the ‘sounds good but is not much use in practice’ tends to fall by the wayside.


What was the lowest point in your career and how did you persevere?

I applied for a Wellcome Trust Programme Grant to research the blood-brain barrier in the pathogenesis of small vessel disease in about 2006. It was a huge amount of work and was based on relevant pilot data, but was turned down as the committee (in its wisdom, none of whom were experts in the blood-brain barrier or even in stroke) did not fundamentally believe that there could possibly be any relation between the BBB and SVD. Anyway, here we are and guess what, the BBB has not only a role in SVD but increasingly also appears to be involved in Alzheimer’s disease. Who knew? It just shows you have to stick at it if you have reason to believe that your hypothesis might be right.


Have you ever felt like you faced more challenges than your colleagues, being a woman in stem?

Yes. All the time. I did not appreciate just how much women and other groups are disadvantaged until I was a professor with a large research group. It became apparent that the only explanation for my being missed off committees or taking longer to get grants or papers published was due to being female. There is substantial evidence now to show just how persistent discrimination there is, most of it unconscious. Some of the worst perpetrators in my experience were other women, often office staff, who would fall over themselves to help my male colleagues but look at me as if I was being unreasonable when I asked if they could help me in the same way. The fact that I even had to ask was very telling.

I do not dwell on this since this is not healthy, but I have the evidence handy in case it comes in useful, insist that all groups with who I work, including committees, are aware of and avoid unconscious bias, and encourage and promote women to step up to the next stages, go on committees, at every possible opportunity. We will only change the culture, and it is a massive culture change that is needed, by having more women at all levels but especially in senior positions and who support each other and are prepared to speak out and call out unfair (and inappropriate) practices.


Did you find it challenging to maintain a good work-life balance?

Yes. But being a single parent teaches you how to prioritise and maximise efficient use of your time and how to switch between work and caring roles – a change is as good as a rest.


If you could give yourself three pieces of advice when you started your career, which ones would they be?

Don’t believe a word until you have satisfied yourself with the facts. If it looks and sounds odd or unlikely, it is probably odd and unlikely. Follow your instincts – sometimes gut feeling can tell you about the right choices in ways that logical reasoning won’t. Logical reasoning, weighing the pros and cons, is important, but if you fundamentally don’t like something, then it is not likely to turn into an enjoyable experience. And have quiet confidence in yourself – your opinions are just as important as the next person’s, so be prepared to speak out and hold your ground.

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