Y-ECCO Interview Corner: Johan Burisch

What got you into medicine? Are you from a medical family?

My grandfather, Povl Riis, was a very famous gastroenterologist, well known internationally. He was a co-author of the Helsinki Declaration. He was very involved in medical ethics. He was the one who initiated work on IBD in Copenhagen, which has launched the careers of many people, especially epidemiologists from his era. But when I started medical school, I didn't know that. He was just my grandfather.

Johan Burisch © Hvidovre Hospital

When did you realise your grandfather’s importance?

That would have been in the fourth semester, second year of medical school. I started noticing that I was shown around and introduced as “Riis’s grandchild” – like I was some exotic animal. Slowly, I got to understand his importance for them and for the medical field. Many physicians aged 60 years or older know him because he had a very strong media presence. He was very gifted and very talented, a good clinician and researcher.

You yourself got into research quite early in your career – how did that happen?

In the second year of med school I had to do my Bachelor thesis. I actually asked my grandfather where I should do this, because I had to find a subject. And he said, go to Pia Munkholm, who then became my mentor and supervisor. Fortunately for me, she was happy to supervise my Bachelor thesis: even in the first email she was already planning what I would then do for my Master’s thesis, which would lead on to my PhD. That was in the email reply that I got when I first contacted her. That all ended up with me being with her for the four remaining years of med school, preparing my PhD and then going directly into a PhD.

At that time, I was the only one, I think, from my whole year at the university who did that. Now it's much more common because the competition has got more intense. But at that time, everybody thought I was an idiot because I didn't go directly into clinical training. It was difficult because all my peers were in clinic. When we met, they were telling stories about patients and I was doing data and everybody thought that was boring.

What was the first type of research you were involved with?

I did a review on defensins and IBD. And that actually ended up with me going for a couple of months to Stuttgart, with Jan Wehkamp and Eduard Stange, who at that time were publishing a lot on alpha- and beta-defensins and their influence on IBD. I spent some months in their lab and found out that I'm not going to be a basic scientist or a lab scientist. That's not for me.

Why not? Was it about either not wanting to do lab work or was there something else that you found in the meantime that was more interesting for you?

The lab process seemed to be much slower and I preferred to get some real answers within a reasonable timeframe. Setting up a whole model and validating testing – that takes a long time and wasn't for me.

 And what area did you then move into once you decided that lab work wasn't really your thing?

I then started doing epidemiology. That was where Pia, my supervisor, came from. And we started preparing the European EpiCom cohort, which now is called the Epi-IBD cohort. Pia was setting that up actually when I first approached her. I think it was a coincidence that I popped up in her life and then she could quickly see that would fit nicely. That cohort ended up being my PhD.

You had what sounds like a very productive and successful PhD, which you then took into epidemiology. Presumably at some point you then did have to go back and do that clinical work. How did that happen?

I finished my PhD and then had a two-year rotation, as happens in many other countries. After that I moved on to the next clinical position, which in Denmark is a one-year introductory position prior to specialty training. I knew that I would go into gastroenterology because I've been in that field since the second year of med school. That was natural. But I was very nervous before starting my first position at a gastroenterology unit because I wondered, What if it turns out that it’s really boring working with this clinically? Fortunately, it was fine. At the same time I was able to apply for some funding to keep on doing research on the side. And without a family, it was much easier back then to work all night and so that is what I did. I really enjoyed the research and so I became very driven, which meant I had the energy to work on the research in my spare time during the clinical training. Not so easy now that I have a young family!

And you mentioned earlier that some of your peers at medical school thought that maybe you’d made a bit of an error going into research directly from med school training. Did you feel you were at a disadvantage when you went back into the clinics having had that time out?

No, not at all. Actually, I was three years older. I think I was more mature. When it is the first time you’re out there, and you actually see real patients, it's difficult to find yourself being an authority and having to make real decisions. That was definitely a role I found easier to adopt because I was that bit older. Also, during my research I had included patients in studies, so I had had quite a lot of patient contact that way. My approach to finding evidence was different compared to my colleagues who went straight into clinic after med school. I would go to PubMed and find things that other medical student didn’t. They would look in a book or something.

And then eventually, I think you did postdoc positions, including in New York. Is that right?

Yes. Then at some point, I wanted to do the five-year follow-up of my PhD cohort. That was about two years after I finished my PhD. I got some funding. We got into contact with Jean-Frédéric Colombel and he was so kind to have me for half a year. My wife, who is a paediatrician, was doing her PhD at that time. She got in touch with Marla Dubinsky, I got into touch with Colombel and then we managed to make the move to New York happen. It was only six months; I would have loved to stay longer. But due to my wife's PhD, we had to go back eventually. Working there was great, getting a new perspective on things, being in another city. New York isn't a bad place to be during the summer. I managed to get some collaborations going and to write some of my five-year papers as preparation for my doctoral thesis, which is the step above the PhD. That was a good year, I think.

What is your current work situation?

I'm still in training. I have a little bit less than two years left. I have one day per week dedicated to research. I have a group of PhD students who I supervise, often at distance because I'm not in the same department as them as I'm rotating due to my training. That is a challenge, but it can be done. I have my group now. I do my own projects on the side, while doing clinical work 80% of the time.

And how do you find trying to balance those two roles? That’s the key question for clinical academics throughout their career: Do you find that balance easy to strike?

No, of course not. Because clinic takes up a lot of time you need quite a lot of discipline to keep the research going. You have to avoid taking a break between two colonoscopies, and instead use that break to write those three emails or read that paper or write that review to maximise use of your time – which is not always possible because sometimes you’re just too tired. But that's something I try to do. It's challenging at home because, of course, I need to spend a lot of my free time on this, on my research.

Luckily, I have a wife who lets me do this. But I think for everyone this is something that causes conflict sometimes because it's a question of priorities. I have no good solution how to do this. I feel that I'm very lucky that I have a family that understands that this is what I want to do. I am also happy that I have colleagues who know that I'm very dedicated to research and are flexible in letting me pursue that. They understand that if I'm suddenly gone from the wards, I haven't gone home. I'm just sitting somewhere and doing something else. But I'll be back and finish my work. My colleagues are very supportive. My aim is to have a position where I get some more time for research. But I also want to do clinical work, of course. That's very important for me. I think if you do clinical research, it's difficult to keep your work relevant if you don't see patients, at least at the beginning of your career. You might be able to do that when you are more experienced and when you're older. But at least in the beginning, you still need to train your clinical skills and you need to get the ideas, get the inspiration from meeting patients and seeing what they ask, what they need.

What have you been inspired by your patients to research? What research projects are filling your time at the moment?

Right now, I’m spending a lot of time doing a project where we are looking at all the newly diagnosed patients within Copenhagen counties. That's a quarter of the population of Denmark. And then we are collecting lots of samples from those patients with the aim of predicting disease course already at diagnosis. Of course, that's not a unique idea. But we all see those patients at the very beginning, and they ask us, “What can I expect? You've just told me that I have a lifelong disease.” It is difficult to answer that question. For many patients this creates a lot of frustration – that we can't really tell them how things will be.

We are also working on collaborations with dermatologists and rheumatologists, because that's another gap in our knowledge. Patients with extraintestinal manifestations or co-occurring immune-mediated diseases can be a clinical challenge. This is particularly true in Denmark. It can be difficult to coordinate treatment when different specialities are often located in different places. Sometimes patients are lost between the systems. That’s why we’re also looking into this as a topic.

Sounds like you have a pretty broad palette of research projects, including translational. However, a large proportion of your work has been in epidemiology. Is Denmark a good country in which to do epidemiological research?

It's a fantastic country because we have nationwide registries. The registries open up huge possibilities, but they have many limitations. We often need to rely on manually collected cohorts. In many cases the centralisation of care that we have in Denmark makes that easier. We have free healthcare and centralised services for more complex or rare cases. For example, pouch surgeries are only done at a very few sites. This means you can very easily get everybody who has had a pouch within the area, which improves the validity of your study. We are challenged by the legal aspect of this because Danish lawyers are very restrictive in their interpretation of GDPR. That is a big problem at the moment. The other limitation is that the population of Denmark is not so big. When you start doing research into some of the rarer manifestations, the smaller subgroups of patients, then the numbers of patients available is a problem. For those patient groups it's easier to be in a country with 60 or 80 million inhabitants or even 300 million. Then you have a bit more to work with. That’s the challenge. Organisations like ECCO really have a lot to contribute here – to act as a platform or forum for creating collaborations.

Moving on to ECCO, you've been the Y-ECCO Chair for two years. I think this is longer than usual because of the pandemic. How do you see the role of Y-ECCO within ECCO?

I think we are the ever-present reminder to the wider ECCO Community that they need to get the next generation involved in ECCO. I think our role is to make the most out of the educational aspects that ECCO can offer and get the next generation ready. However, I think trainees could be more involved in the organisation. If you compare ECCO with other organisations, young members are much more involved or are present in governing committees.

It's deadly for an organisation if the same 20 people keep rotating between the committees because you don't get fresh applicants. If you look at ECCO right now, we see many of the people doing great work in the various committees; they've started in Y-ECCO. It's an entry platform into committee work in ECCO. For example, the last two presidents have been Y-ECCO Members. And the next group of people that are approaching OB have also been in Y-ECCO. It's a good place to start.

What projects have you overseen during your time as Y-ECCO Chair?

We have been working hard to launch the mentorship forum, which unfortunately has been delayed due to the pandemic. The idea is to give many trainees, including those training in countries where they do not have access to Key Opinion Leaders, the opportunity to connect with people who are really excellent, brilliant researchers who can teach them and mentor them in their careers. I think ECCO has an obligation also to help with that. We are hoping that during the mentorship forum in June 2022, trainees and young physicians will have the opportunity to interact and to discuss careers, how to set up studies and how to reach the goals that they might have. It might even be possible for them to connect and get collaborations ongoing.

Another big part of the work of the Y-ECCO Committee that you oversee is the Y-ECCO Basic Science Workshop. Could you tell us about what that is? Should Y-ECCO Members sign up for that or is it just for basic scientists?

The Y-ECCO Basic Science Workshop is a workshop that we have prior to the conference where we pick some topics in basic science and get some excellent speakers to discuss this on a level that is for trainees and not necessarily for the great tech audience that might be at the conference. And you definitely don't need to be into basic science although it probably helps a bit to have some grounding in basic science. But it is definitively a valuable workshop for clinicians in training. It might even inspire some people to get into this part of research. We select the best abstracts in the basic sciences that are submitted by Y-ECCO Members. Those individuals get the opportunity to give a talk in front of a limited audience, maybe an audience where more questions can be asked. It's a different atmosphere in a room with, say, 50 participants compared to 6000 people in the main hall. We allow more time for questions after the presentation than is permitted in the main sessions so the scientific discussion can be in more depth. This is enhanced by the keynote speakers, who also contribute to the discussion of the work that goes into the abstracts. Often presenters go away with some great advice or ideas for their research project! It's a long tradition in Y-ECCO that we’ve done this workshop and I think it's a good supplement to the main conference.

What other projects does the Y-ECCO Committee oversee at the moment? Are there any other ways that Y-ECCO Members can become involved?

We have a survey that is distributed during the conference. This survey is chosen from research survey proposals submitted by Y-ECCO Members. The Y-ECCO Committee select the best application and this will then be chosen as the survey that we do. That’s an excellent way to get involved in ECCO because there's support from the office and there's support from our committee. Usually the survey results in a publication.

We are also developing a communication toolbox. The aim of the project is to create short audio files – like a podcast, where we explore how to answer questions patients might ask in clinic. We have generated a series of common questions on everything to do with IBD, including sexuality, cancer, surgery, pregnancy and so on. We selected the questions in collaboration with patient representatives. Then we asked all ECCO Committees to help us answer these questions in a way in which we would talk to patients. The idea is to provide some of the experience that a trainee might have if they were observing a clinic with an IBD expert and got to hear how they tackle these questions with a patient.

What have you learnt in your time as Y-ECCO Chair?

The pandemic just made things a bit problematic. I think it has taught me the importance of seeing each other physically. It's just difficult to keep committee work going if we don't see each other at least once in a while. But on the other hand, it's nice to meet people who share the same interest as you, who are also very dedicated, very motivated to do this, even if those meetings are digital. If you're lucky, you get to work with people who do something completely different from you – in that way you learn new things, new aspects of the field. I enjoy that very much. The other aspect that is hard not to admire is that all of this is done in people’s free time. Everyone has a lot of other things to do, but they choose to do the work in ECCO because they believe it is important. That is very motivating.

What do you do when you're not working? Or are you ever not working?

I do sometimes take a break! I do a lot of biking. I’m trying to be a professional amateur. I also play a lot of chess. I played chess when I was in ninth grade but stopped quickly because there weren’t many to play against. A couple years ago, I rediscovered chess and actually started in a chess club at the age of 35. I started chess because I was tired of going to Facebook or Instagram when I had to have a five-minute break. So instead, I started to play online chess in those breaks instead, because I felt at least I get something out of it. But chess is an extremely addictive game. You think you will only play one game, then you win it and you say, I can't stop now – I need to play another game because I'm on a streak. On the other hand, if you lose, you feel you can't stop now because you just lost. So, I sometimes wonder if it actually takes up more of my time than browsing different websites on the Internet. Of course, I also have my two children and my wife and I try to be as good a father and husband as I can. That takes up a great deal of my time when I am not working.

Are your children old enough to play chess with you yet?

I taught my eldest child and she is able to play. But I beat her very brutally because I wanted to stimulate her to get better. However, that resulted in her being so unhappy with the game that she doesn't want to play with me anymore. Perhaps I should go easier on her next time!

You mentioned that you are aiming to be a professional amateur cyclist? What does that mean?

That means that I train three to four times a week and I attend amateur races. I have done races, for example La Marmotte, which is an amateur bike race where you go across three of the Tour de France mountains. I do crazy stuff like that where you sit on your bike for nine hours and you climb up mountains and torture yourself for half a day. Cycling is nice because it empties my head. It's difficult to think of anything other than the need to keep pedalling. You can’t think about deadlines, patients. That’s very nice. And chess is good because, again, you can't think of anything other than chess because you will lose if you don't concentrate. Again, you empty and clean your head.

Your time as Y-ECCO Chair will be ending at the next year. What's next for you within ECCO?

Right now, I need to focus on finishing my specialty training. I also have too many ongoing projects right now as well as several PhDs to supervise. So just now I am going to take a break. I am still involved in some of the ECCO Guidelines and Topical Reviews because I enjoy that very much. It's a fantastic way to being forced to dig into a topic that you may or may not be very familiar with. I'm going to continue doing those, but when it comes to committee work it's going to be a short break for me. However, I am looking forward to the ECCO Congress in 2022 as well as to our mentorship forum – it will be exciting to meet in real life!