MetaCast

Hello, everyone, and welcome to MetaCast, the podcast of the meta analysis academy. My name is Rhanderson Cardoso. I'm a cardiologist here in Boston. I am a professor in the Meta Analysis Academy. And today, I have the honor, the absolute honor, of hosting in this podcast Andre Zimerman, who is an a phenomenal researcher.

He's from Brazil like myself. He came here to Boston for a research fellowship. He's going back now to lead research in Brazil. So I'm incredibly excited to have this conversation with Andre. Before I hand it over to him for introductions, I want to mention that this cast, the Medicast, the meta analysis academy are not affiliated with the institutions where we currently work.

The opinions here are exclusively ours. I also want to explain to you if you're new to our channel, to the Meta Analysis Academy, I want to explain to you what is the academy. This is a institution that teaches systematic reviews and meta analysis at a very high level. We teach methods, statistics, and writing, and we do that so our students can achieve publications and advance their careers and achieve their goals. We do not do publications for our students.

We do not guarantee publications. All the publications are the exclusive responsibility of the study authors. So with those disclaimers, I'm going to hand it over to you, Andrei, for introduction. Thank you so much for being here. I'm honored by your participation here in Metacast.

Can you introduce yourself, please? Yeah, sure. Randerson, so first of all, to me, it's an absolute honor to be here with you. You are a huge friend. You are an incredible cardiologist researcher.

It is an absolute honor to be here in the podcast talking to you today, especially about these things that we both love, that is teaching, research, and cardiology. So it really could not be better. As an introduction, I'm Andre Zimmerman. I'm from Porto Alegre, Brazil. I did my whole medical training in Brazil, my MD, my PhD, and then I came over here to the Brigham and Women's Hospital to the Timmy study group to do a postdoc research fellowship, a 2 year training in clinical trials and clinical research.

And this is my current position right now, and soon, I will be back to Brazil to the city of Porto Alegre, where I'll I'll lead, clinical research, clinical trials unit back there in our home city. Fantastic. We're gonna we're going to every little bit of that incredible journey. Andre, I want to start with how you developed an interest for research. It's very common for people from Brazil where we're from, probably from other countries around the world, to go into medical school and have primarily a clinical focus and should be really directed towards, you know, learning how to do surgery or cardiology from a clinical perspective and not so much develop a research oriented career.

So in your own, career, how did this passion for research developed? When I started medical school, I did not think about research, but that's the beauty about being in college or med school where you're just exposed to so many different things, where you'll eventually figure out what you like the most and what you do well. I was exposed to research relatively early on there back in my 2nd year of medical school. And honestly, I hated it. I did not like it at all.

I was just getting Excel spreadsheets, putting data in there. I thought that was research. I thought it was very dull. So back then I decided I would not do research ever again. That turned out pretty wrong.

But luckily, after a few years, I had the opportunity to do an exchange program from Brazil to I went to Columbia University in New York where I had a 3 month training at Duke, at the Duke Clinical Research Institute, which is an institute focusing on clinical trials. And there, again, I had the opportunity to do research, but there it was completely different because they already had the whole structure, they had the trials. So there as a, I basically functioned as a fellow even though I was in medical school, There instead of just being the guy who, you know, collects data and never sees the end result, There was basically the opposite. I needed to have ideas. I needed to think about analysis.

I needed to write. So at that point I figured out, I actually like this thing because then it was a lot of stuff that I was interested in, which was math, statistics, communication, writing, presentations, a lot of stuff that actually I liked and I did pretty well. So at that point I realized, I actually like research. And from that point on, I started seeking every opportunity I had to learn more about research, both in the theoretical level doing courses, learning biostats, learning epidemiology, but also in practice, participating in clinical trials back in Brazil, in my institution, other institutions, looking for mentors who could give me this training. And from that point on, I decided that I wanted to pursue research more as a career, even more so than seeing patients at some point.

So I developed this gradually over the course of about 5 years until I finally realized what I really wanted to do. How did you get that opportunity at Duke? What because there's a lot of people who would be interested in having some sort of similar experience in research to figure out if they like it, if they wanna do it as a career or not, but they have that entry barrier. So how'd you get that opportunity? During that time, there was this program in Brazil called the Science Without Borders program that sent students abroad for training.

So that's how I ended up at Columbia University as an undergrad. During that period, they had a 3 month time where it was basically vacation, but you had to do something. So I decided I wanted to do research and I knew about this Brazilian professor at Duke, Professor Renato Lopez, who is this huge Brazilian trialist. So I talked to him and it was I'd say relatively easier because I already had my funding from the program but then I talked to him, he saw my CV, we chatted, I told him about my interests and then he put me into the zoo clinical research institute. So that's how that opportunity came along.

But more generalizable to other people, I'd say that these folks who are in this position where they are, let's say, in this position of power where they have been there for a few years, they are professors, they are the PIs. These people want to help you. They want to help other people. I can't start to enumerate all the opportunities that I've I've had just from reaching out to people who I thought would never answer back. Yeah.

And they did. And they really want to help because they have been in your shoes 20 years ago. They see a young, honest, hardworking student and they want to help them just like at this point we want to help some students who come look to us. So so if I had one tip for other people who are in this position is don't be afraid to reach out to show people what you want. These people want to help you, they want to give you these opportunities.

My story is by no means a story that's unique or that just happened to me. Even in my trajectory, I have like 3 or 4 of these where I reached out to random people and they ended up being huge mentors who made the whole difference in my career. So I really encourage people to reach out, to try to talk to these folks. This can really make a difference. I'm not sure dwell too much on this point because we have a lot to talk about, but I would say that the key in doing this, and you can correct me if I'm wrong, but would be to obviously, with this initiative that you sort of have explore your connections.

Like, if you know someone who knows someone and you've caused a good impression locally, so that's another thing that's super helpful. If you have people that would recommend you, people that know that you're hardworking, that you are an honest, good person to to use your own words. And then, if you can bring something to the table, and that's not always possible, but if you if you've shown results already, if you've demonstrated some prior work that they whether it's that you know statistics, you know how to write, or you have time available to work on a research project, these are all things that you can bring to the table so that it's not just you extracting the benefit from that relationship. Would you agree? I agree 100%.

Obviously in these cases these folks have much more to offer you than you have to offer them. But that's how it works. This is the sort of thing that you pay moving forward. However, if possible, just like you said, if you can bring something to the table, something that even if it's 10% Yeah. And they come in with the other 90, that completely changes the game.

So I've had some of these where I've worked with people who are much more senior than I was, but I knew how to program an R, for instance. Right. So I ended up getting into trials and papers just because I knew how to do basic things in R, and they needed somebody to code a certain graph. Yeah. And then I did the graph and reviewed the paper and I was in the paper.

So stuff that really helps you if you have something to offer that the other person does not have, some skill, if you bring something to the table that really can make a huge difference in these kinds of relationships. That's exactly what I meant. What a great example. I fully meant the the 10, 90% or maybe even 5%, 95 percent. You know, you just you gotta bring your little contribution and then these more senior pis or investigators or researchers will then take care of the rest.

Andre, I really want to explore here in this podcast the this contrast and the opportunities for research in both from Brazil and the United States. So let's talk about your transition into the US. How did you come here for this research fellowship? Yeah. I always knew I wanted to come to the US, especially after a certain point where I really decided I wanted to focus on research and clinical Brazil or any other developing country and the US is really huge, different than for certain clinical aspects where the gap is not so large.

So, for research, you really have, here you have way more funding, way more opportunities, you have a structure for clinical trials with academic organizations with pharma that you don't have in developing countries. So I knew that I wanted to come over to the US to really learn about this stuff. And I've helped run some trials in Brazil before I came over here and the big difference is the funding, the structure. Because you have some really, really good people in Brazil as well, really smart, really hardworking people. But here in the US, you really have the funding, you have the structure, you have the organizations, and you have people with way, way more experience.

So that's what I think really makes a difference at the end of the day. I've run some very nice trials in Brazil, but the level of rigor, the level of scrutiny that you have here in the US and specifically at the Timmy Group where I was is something that is unparalleled in Brazil or any other developing country just because of the amount of time and funds you need to run a massive global trial operation. I mean, these big trials can be more than $1,000,000,000 Of course, this is invested mostly by pharma along with the participation of CROs, academic organizations, but it's an amount that's basically in a global scale and the opportunity to be here at Timing Group and be a part of this, being a very, very small cog in this huge operation was very life changing to me. So tell folks about the Timmy group. I mean, it's such a powerhouse in research and clinical trials, and you've worked with them for 2 years.

It'd be great to get your, you know, your insider perspective on what explain what is the Timi Group and what it was like to work with them. The Timi Group is an academic research organization or basically a unit that develops clinical trials from an academic perspective. It's affiliated with the Brigham and Women's Hospital and Harvard Medical School founded in 1984 by Doctor. Eugene Braunwald and really picked up since then. Now we're at the 77th trial, currently Timmy 77, the Coral Reef trial.

And Timmy really deals with all academic aspects of running a clinical trial from inception, thinking about the idea, developing the protocol, the sample size calculations, the statistical methods, up to running the actual trial operations. We have operational meetings several times a week. We look at recruitment. We talk to the national leads from each country to help recruit patients in those countries, we work really closely with the CROs, with the sponsors, to ensure that the whole trial operations are running smoothly. At the end of the trial, closing out the sites, running all the analyses, writing the papers, publishing the papers, and even after publishing the main results and presenting in scientific conferences, we stay with those data sets to run additional analyses with other interesting questions that may arise even after the main results are published.

So even though Timmy has 77 main trials, the number of actual publications is orders of magnitude larger than that I mean the engage trial alone has almost 100 papers that came out of that just because the data sets are so good and so rich that it really gives you huge opportunities to develop additional research projects and answer questions further by using those datasets. That's incredible. And then, what's the perspective of being a research fellow there for 2 years? How does it work? You do you get assigned to 1 mentor?

I'm sure there are multiple PIs in the in the Timmy group. So explain to folks just, exactly how it works from someone who's coming in to work as part of such a amazing or large academic research organization. Obviously, we're talking here about Timi, but this may be generalizable to other opportunities that people may have doing clinical trials in other centers. So at Timmy, my work week was basically fiftyfifty. So half of the time I was helping run ongoing clinical trials.

I was assigned to a few trials, trials with COR, COR 2, S and CS9, BRIDGE CS8, focusing on olezarsen treatment for hypertriglyceridemia. I was a fellow in the GARDEN trial with poxagramab for patients with, it's an anti GDF15 for patients with advanced heart failure and the CORO REEF trial, which is a new oral PCSK9 inhibitor for patients with elevated LDL cholesterol, basically. So roughly half of my time, I was dedicating to running these trials as a small cog in these huge operations. So as a fellow, we would review the protocol, review the statistical analysis plan, talk to the sites. If any sites had questions, they would call us.

We would answer. We would answer emails. We would present in site call in hours where they would pop in, ask questions, we would answer. I flew to Europe to present the protocol to European investigators. We it's a lot of stuff that you really can't anticipate, just putting out fire after fire as the trial moves along.

So that's roughly half of the time where I was here learning about trial operations, which is something I didn't value that much before I came, but now is really essential to my position going back where I'll have to run my own trial. So learning about how to operate a clinical trial, especially these trials that operate on global level was a very, very rich experience. Then the other 50% of the time were focused on my own analysis using the Timmy data sets from prior trials, published trials. Each trial that is published, it goes into, let's say, the New England Journal, JAMA circulation, but then that's only where it's, that's, let's say, the starting point. That's the easy part.

After that, you have a huge data set with very rich information with answers you can tackle. So roughly 50% of my time was answering these additional questions using these very rich data sets. So I develop a bunch of projects here with a lot of different mentors. That's the beauty of being in a place that is as large as Timmy. You can learn from many different mentors to learn their perspective from each.

Here I developed studies mostly in the areas of prevention, cholesterol, but worked closely with mostly Bob Giuliano, Nick Marston, but also several additional mentors, Mark Sabatine, Michelle O'Donohue, Brian Berg, Mark and so on, so on, who really helped me get a different, each of them brought something different to the table that really helped me develop as a researcher. And now I'm still wrapping up these projects, but let's say like 10, 15 different projects that I was leading that is really an integral part of being here. So all of this, having the experience to be a small part on these huge clinical trials, global trials, But at the same time, having my own analysis where I am leading with the support of these world class mentors was really a tremendous experience all around. Yeah. That's such an incredible contrast to the type of research that I do, for example, where, a primarily clinical person like myself is involved in in projects.

You know, some of them are, like in my case of cardiac CT, some of them are industry funded and, I do also some like, epidemiology work, a lot of meta analysis, of course, but it's totally different than just, like, being dedicated to clinical trials and, like, running your own analysis, the secondary analysis of prior datasets that have been, previously published in in other forms. So it's just an incredible experience. I mean it it almost, it's such a it's such a huge contrast. Do you have recommendations for people who, whether from the US or Brazil or anywhere else, for people who wanna get into this type of research career of really doing and learning clinical trials, doing that as a career, what would you recommend? A few things.

So first, well, first read a lot. Read a lot of trials, do courses, read books. There is a lot of training in the sense, but theoretical training can only take you so far. For this kind of stuff, you really need to be in the weeds. You really need to learn from people who are doing this kind of stuff because there's so much that's under the hood that we don't really see just by reading a paper.

That's so, so much that's really, between the lines. So I would suggest a few things. One is there are dedicated programs such as research fellowships as the one I did, such as the ESE and Oxford have, dedicated MSC in clinical trials. So try to learn from people who do this on a regular basis and who really have stuff to teach you. In addition to that, you need to be doing your own stuff.

You can't just read about it and learn from someone. You need to do your part. Just like here, I was running some, running several projects, but even in Brazil before I came, I was running several secondary analyses of clinical trials. So get involved, talk to people who have the data and have the expertise to basically give you what you need both in terms of data sets and in terms of mentoring. Talk to these people, show them you are interested, you want to learn and the opportunities start popping up.

I started out about 10 years ago doing a small trial back in my hometown in Brazil that really helped me learn and see how this is done. I was interested, I talked to more people. I ended up being involved in larger trials both from a local site perspective and an executive committee perspective still in Brazil even before I came to the US, I started running my own secondary analysis of clinical trials. And at this point there are several ways you can get those data. 1 is talking to the people who have the data but also simply going online and requesting data sets.

Like nowadays there's so much you can do by getting the data from the UK Biobank, from the Yoda project, for instance, all these websites that can give you access to free data. So being in a position where you identify a few mentors who you will learn from and who can open doors, but at the same time, start doing your own analysis, you do it, they won't be perfect the first time or the second time or the 10th time, but you'll learn a little bit along the way And having mentors to help you with this process, I'd say this is the way to go. And honestly, back 10 years ago, the world was much more, let's say physical. I had the, I was fortunate enough to already live in a digital era where I sent an email to Renato Lopez. I sent an email to Otavio Berwanger who is a professor in Brazil, lived in a city that was different than mine and became a huge mentor as well.

So I was fortunate to be able to contact these people even from a distance, something that was impossible, let's say 30 years ago. But today, you can be mentored by someone and not even live in the same country, which is huge for everyone who's starting right now. So people should really use this and leverage this to their own benefit, to get access to world class mentors regardless of where you come from. Yeah. That's and the other point to highlight here is that it's just like one step at a time.

Right? I mean, this your the way you are now in your career, it's just incredible. We're gonna talk about how you're gonna lead clinical trials there in Brazil, but it's not something that just happened, you know, from day to night. You used to build this, you know, over 10 years much like, other people have built like clinical couriers. Obviously you have that as well, but just it's just one step after the other.

Yeah. And you need to be careful not to try to go 3 steps at a time. So I like what you say about going one step at a time. A lot of us look at someone, some mentor, someone who we see as a hero. And I look at that guy.

He's 6 years old. He's running the clinical trials unit. And I think, let me see what he's doing and let me do the same thing. But that's the wrong way to look at this. You need to look at that guy and think, when he was my age, when he was in my stage of career development, when he was 20 years old, what were the skills that he was learning that allowed him to get there in this position when he is 40, 56 years old?

What are the skills, the foundational skills I should build right now to be in this position in 10, 15, 20 years? Yeah, that's a great point. Now you were talking about the activities of research fellows and the TIMI group, so let's talk a little bit about the results. Can you just share with folks a little bit about, you know, the number of papers or the conferences that you've presented and which journals you've published in before and during your time here? Yeah.

So before let's do these separately. So before I came over here, I had the opportunity to be involved in several different lines of research and develop several papers from Brazil and from a prior experience here in the US. We had my first clinical trial. We gave caffeine to patients with advanced heart failure. We had this idea that people with heart disease could not ingest caffeine.

So basically we got patients with advanced heart failure with ICDs, gave them 6 cups of coffee and put them to run-in a treadmill. And then we did a crossover, did the same thing, but with decaf coffee, saw the number of arrhythmias was the same in the 2 groups. That was really well published, JAMA Internal Medicine, even though it was developed in our, the single center hospital in Brazil, got a lot of attention from the media. That was my first experience in clinical trials. And that was actually really amazing because we did that in about 50 patients, But then quickly, people from all over the world were talking about that.

And just the idea that your next patient will come in and they will ask you, Hey doc, is it okay if I can continue drinking my coffee in the morning even though I have the heart problem? And to be able to look at them and say, yes, it is fine. And we know that because of something I did. Even though I was just a student at the time and obviously my contribution was very small, the idea that you could generate some data that could help some patient in Japan Yeah. Who lives 10 years from now, that was an amazing experience and really inspired me to do a lot of the other projects that I ended up doing.

So after that, I got involved with larger clinical trials in Brazil, the VIPACS trials with the folks in Albert Einstein Hospital in Sao Paulo that was supposed to be a 9,000 patient trial with influenza vaccination during the hospitalization for an acute coronary syndrome. Ultimately, the pandemic started, everyone was wearing masks, no one had influenza anymore. We had to stop the trial short with 1800 people. We published that at the European Heart Journal, but just all these experiences in doing clinical trials in circumstances that you also cannot foresee you are very rich. At the same time, I had another line of research here with a researcher here in the US who's an economist and a physician, which was completely different from clinical trials.

Here, we had some Freakonomics sort of ideas trying to come up with creative stuff and did a lot of research pairing data sets, basically econometric research, and completely different from anything I had ever done at that point. And we also did some lines of research, one of them we published in the New England Journal, went to BMJ, went to circulation, with these different creative ideas. So all of these prior experiences, even before I came here to Timmy, helped me solidify this knowledge and skill set and the creativity that I think is necessary for clinical research even before I came here. So I also think that highlights the usefulness of having different experiences with different mentors who can teach you different things, so that when you come to a new challenge, you have a lot of different skills in your toolbox that can help you with any challenge that is posed. Nice.

I mean look at the level of those papers. I mean, Gemma Internal Medicine, European Heart Journal, and that's just before Timmy. So, what about during during the Timmy? I know you just recently had a participation in a trial that was published in the New England Journal of Medicine. So tell us a little bit about the the the results, just the journals where you've published, the presentations that you've done during your 2 years as part of the Timmy research group.

Yeah, so at Timmy, as I said, we have these 2 main parts. One of them is, let's say being a small cog in these ongoing trials and the other one is leading our own projects. The paper you mentioned is part of the core program with olefarsen and APOC3 inhibitor for patients with elevated triglycerides. This was the smallest of the 4 trials and we were fortunate enough to publish in the New England Journal of Medicine, which was a huge experience just to be part of this group, to understand the scrutiny that is involved with these processes and the FDA audits and the New England Journal requirements, and seeing the back and forth with our groups, the stats groups, the sponsor, that was a very fascinating experience. And I still have 5 ongoing trials that I've been a part of, and I will still work on these papers eventually at some point.

And from the other end to projects, the secondary analyses from prior trials that I am leading, There, we're doing anything between, I think, 1015 secondary analyses of prior clinical trials, mostly focusing on cholesterol and LDL lowering, triglyceride lowering. Most of them are still ongoing either under revision or just submitted, so we have a few of those. I have published so far 2 both in lipid journals, European Journal of Preventive Cardiology, Journal of Clinical Lipidology. Now a third one that will be published in a large medical journal, probably tomorrow, focusing on low dose anticoagulants in elderly patients. But then we also have several additional papers that are under review at this point.

And we know that research is a prolonged process, so all of these will probably be published anywhere between 6 to 18 months from now. These projects usually take like 2 to 3 years. That's incredible. I mean, just the the the level of the journals of the papers, you know, really, impactful in clinical care, like you said, on a large scale. It impact the lives of patients from all over the world.

You actually have a good story about that on how, one of your mentors said, you know, if it's not gonna change practice, you know, we better not even do it. Can you can you share that? Yeah. So the mentor I told you about, the guy who's an economist and also a physician, completely different than anything I've had in academic medicine where people, you know, are more formal, let's say. So when I went there to meet this guy, I was wearing a tie.

It was Boston. It was really hot outside. And then he looked at me. He was wearing shorts, a t shirt. He basically looked at me and said, what the hell are you doing?

So I took out the tie, he took me to have ice cream and that's basically how our relationship began. And one thing that he said that really struck a chord with me was I remember one time when I had this idea and I told him about that. I said, look, what about if we do a, b, and c, what do you think? He said, well, that's a pretty interesting idea, but let's say everything works out exactly as we expect. So, Andre, imagine that we do this, we get the results that you hope we will get.

What do you think will happen then? Do you think we will publish this in a good journal? I said, yeah, maybe a medium tier journal, not a really good journal. He said, okay, so we're not publishing it really well. Do you think this will impact the lives of people?

I thought, well, honestly, I don't think it will. I think we have some methodological flaws. And he said, well, then even though the idea is interesting, I'd rather go out and play soccer. And he really did. We really played soccer like 3 times a week.

And that is a message that I hold closely to my heart to this day. That is time is the most valuable resource that we have. We should not dedicate time to anything that's not worth it at the end of the day. So we should not do a project just because we can. We should do it because this will change the lives of patients, of people.

This will help somebody. If before starting a project, you think about it carefully and realize that even if it works out exactly as planned, it will still not help anyone, then it's probably a better idea to just to kill it right then and focus your time on something else. So that is one thing that I think about a lot to this day even before or before starting any new project to think, well, is this worth it? Will this be published? Well, will this change the lives of anyone?

And that really guides me to make my decisions about what is worth pursuing or not. Yeah, I know that's such an important message. You know, especially I think as we're starting out, I think it's also different at different stages of our career. Right? I mean, at the level of your mentor and at your level right now, you may not be interested in a paper that's not gonna really, change the world.

But I think it's just to get the message to our audience who is in a very different stages of training in different countries from all over the world, at some point in our career, we we all do things, you know, that we need to we need to get it published. We need to get our name published. Obviously, you're not gonna do anything that doesn't have any value, but there are also different scales of of magnitude of importance. And at different stages of our career, people will get involved will be more interested and their time will be allocated, best allocated to different orders of magnitude of importance. Would you agree?

For sure, 100%. I think what I wanna say is when you start a project, you need to know exactly what that project will give you. Sometimes it's going to give you a nice paper that will change the lives of people who are reading it. Sometimes I'll just do it to help a student for instance. So a review article, which obviously will do our best, but my primary reason to me is basically to help the guy out because I think it's a good person who deserves this opportunity.

And maybe sometimes I will decide to do a project because I'm interested in working with that mentor even more than the actual scientific value of that project. True. So I think the message is before starting anything, just think about before reflexively saying yes, just think about what will I gain from that and will it change the lives of anyone? Will it help me? Will it help my career?

Will it help develop any kind of relationship? But have this really clear when you decide to start a project to avoid any surprises later on because again, time is the most valuable resource that we have and we want to allocate it to something that will will help us, will help other people. Totally. I wanna, talk about go what you're gonna do in Brazil because I'm so excited about it. I think it's just gonna be amazing for for your career, for the people around you, for the country as a whole to expand the the initiative in clinical trials there, also to get things away a little bit from Sao Paulo.

You know? So there's so many, great things happening. So tell, folks about the job that you will lead over there in Porto Alegre. Brazil is a powerhouse in clinical trials. Even in the trials that are led here in the US, Brazil is usually one of the top recruiting, if not the top recruiter country in the world, just because of the way our public healthcare system is well organized.

We get the patients to the right centers, we have a lot of diversity, we have cheap enrollment. So Brazil really enrolls a lot of patients in clinical trials. And the movement that has happened in the last 10 to 15 years is that Brazil is now not only enrolling patients in clinical trials that are led by other countries, but actually leading their own clinical trials in Brazil. I mean, if we are adding the patients, if we're adding value, at some point we should also lead our own projects. And the questions that we're trying to answer are honestly more applicable to the entire world of developing countries than simply the first world countries over here.

So Brazil has really started this movement of leading clinical trials initially in Sao Paulo that is the most developed city in Brazil but now expanding to the rest of the country and this is where I come in. So I'm going back to Hospital Mui Ezevento, HMV Hospital here in English, that is a leading institution in the south of the country, probably the largest private hospital in Brazil, in the south. And they have started about 10 years ago to really focus on clinical research, trying to answer questions that are relevant to the Brazilian population and more specifically the public sector in the Brazilian healthcare system. And when I say public sector in Brazil, what I really mean is basically public sector in developing countries anywhere in the world. And we have been getting this experience over the last 10 years, but now I'll go back to really organizing start a unit as an academic research organization or a unit that's focusing on coordinating and leading clinical trials over there.

It will be the first one outside Sao Paulo in Brazil, where we will be leading trials initially more focused on the Brazilian population, but eventually why not international trials using the whole Brazilian system of enrolling patients, but actually being there and leading the cognitive part of the trial as well to try and answer questions that are more relevant to most of the world's population. So that's the idea. We will bring all the experience that I've had here at Timmy, try to translate it back to the Brazilian sector, to HMV hospital, to our clinical trials unit there, to try to really robustly answer these relevant questions. Yeah, it's gonna be fantastic for all the reasons that you mentioned. I really can't wait to see it over the next of the over the upcoming years, the results of your work and of, the trials that you will lead in, in, HMV hospital there in, in Puerto Alegre.

Can you tell folks a little bit about where the funding comes from? Obviously, some of what you say may apply mostly to Brazil, but also, maybe other countries too, where we probably have this preconceived notion that all the money is in the US and you have to be in the United States to do clinical trials or potentially some countries in Europe. But, where does the funding come from to do the clinical trials that you will lead in Brazil? Is it interest the industry, the government, a mix of both? Yeah.

Our plan there is to run an ARO, academic research organization, who will really receive any sort of funding, and we will have the expertise to run the trial. Right now, we receive over there a lot of industry funding, but normally as a site, not as the coordinating center, but one of the many sites who are enrolling patients. So a lot of funding comes through industry, but mostly in this scenario. And we already have a lot of government funding in Brazil to run these trials relevant to the Brazilian population. HMV being one of the 5 or 6 leading hospitals in the country, only these hospitals receive this public funding so we actually have this amazing opportunity to receive money from the government to run research that is relevant to our population.

But in these situations, at the point where you develop the resources and the structure to run these trials, then the funding can basically come from anywhere. So you can run these government funded trials. You can run industry sponsored trials at the point when you reach a point where industry realizes that you have the capacity to do this, they start looking for you and you build these relationships where you can do industry funded trials. Investigator initiated trials are also a huge source of funding, of ideas. So you can have these trials that are led by investigators, sometimes sponsored by public funds, sometimes private funds, sometimes sponsored by pharma.

Pharma, they always have these open challenges where you can open grants, where you can send your ideas. So you really have a bunch of different opportunities, not unlike here in the US where you can apply for grants, apply for sponsors, apply for the government, and try to use this to run any type of research, but in my case, specifically clinical trust. It's incredible. It's gonna be so great. I'm so excited for you.

Yeah. And, Andre, this this what's it been like, you know, getting it started? Like this transition that you're about to lead there, I mean, in this service, if I understand, doesn't fully exist in HMV yet. I mean, you're you're essentially leading it. What's it been like the meetings and getting this process started over there?

Yeah, it's been very exciting and also very challenging. There, I'm fortunate that I'm going back to hospital that already has a lot of funding, right? Has a lot of thought leaders, very smart people who have been running trials for a long time. And the institution also has the experience that they have been running trials for a while. So that really makes our job a lot easier, which will be mostly organizing all the structures that already exist into something, packaging into something that is meaningful and strong and solid as a unit to develop clinical trials.

So I've been talking to the investigators, I've been talking to people from each trial, talking to these leading cardiologists, neurologists, intensivists who are now the key opinion leaders there and who are running their own trials, talking to the statisticians so that we can really build something together that makes sense, that not, we don't want to destroy the structure that exists there now. We basically want to build it on top of that using the expertise that each person brings to the table and to build something that's greater than the sum of its parts. But as you can imagine, this comes with a lot of challenges from where do we find funding, where do we get a statistician until like where will I sit down and have my desk because there is no desk for me right now. So this kind of challenge that we are building slowly, but we want to get this ready for when, when I get there, have this whole thing running and have all these trials talking to each other, one learning from the other and build something big over there. This is such a great story.

We're coming to an end here, but at these last few minutes, I wanna talk about what sort of, to to make it more generalizable to everyone listening, what sort of advice, or actually, let me make you more specific the question. What skills do you recommend that people start learning? You mentioned early in our conversation, like, what was Andre doing in medical school? We kinda learned that already by your own history, but what skills should people be learning statistics? Should they be better at writing?

Should they, you know, be learning communication? Obviously, all of the above, but what are the key skill sets that you think people should start to develop to eventually, land a career like yours in a country like Brazil where not many people are going into a research career like the United States and you've done so well, so what's your recommendation? You basically took the words out of my mouth, but I'd say a few things. So first, critical thinking, read papers and learn from the experts, Not only read, but read with a critical view, see what other people are saying, go on Twitter, read the tutorials, really understand what is right and what is wrong with each paper you read, go into the methodology. Don't skip the method section.

Read the method section first and really understand what's right and what's wrong with each paper. That's one thing. 2nd skill is English and reading in English, writing in English, those are the 2 more important skills. Talking English also helps, but really the writing and understanding how to write a paper, how to communicate effectively, both in writing and in PowerPoint slides. Communication is such an important skill that you should really learn early on because people, when they look at you, communication is only 1% of what you are doing, but it's 98% of what people see.

So if you want to really cause an impression, you need to communicate effectively. The third thing is biostatistics and epidemiology for sure. That really is critical if you want to understand the paper and use it to help your patients. But also if you want to understand the paper, do your own analysis and use that for a career in research. And I shall say going one step further, to me specifically learning how to program in R really made a huge difference.

Back then I had a professor at Columbia 2014. I asked him what software should I use? And he said, R, and that was one of the best advice I ever got in my whole career. At that time, everyone in my hospital was using SPSS. I went straight to R and that really allowed me to be one of the first people in my setting to learn this new part, new software.

And a lot of people came to me asking questions, wanting to do advanced analysis, wanting to do certain graphs that I was the only person who could do. And honestly, it wasn't even advanced. It was just that I had learned that skillset. So that really helped me back there. And all of these skills that we're talking about right now, communication, writing, stats, programming is stuff that after a certain point you don't have time to build these foundations.

At the stage that we are now, we are just so busy with so much stuff, we don't have the time and opportunity to go back and build these foundational skill sets. So I always advise people, if you want to do a career in let's say research or anything else, what are the foundational skills that you should learn early on that you won't have the chance to learn later and that you should really focus on knowing that will make a huge difference in your career. And I'd say that for research I'd say these are it. It's communication, writing, stats, programming. If you learn these in a good level early on in your career, that's something no one can take away from you.

If you have one more publication, one publication more, one less, okay, obviously that helps. But if you really learn how to do an advanced analysis, that will give you 100 papers over the course of your career. And it will open up so many doors. Again, we were talking about back there is that you need to bring something to the table. If you can bring this to the table, it will open up a lot of doors.

So if I had to give this piece of advice to someone who is just getting started, it would be focus on the skills, on the foundational skills much more than in the end result. Don't worry about you know, getting one more poster published. If you think that won't, if you don't think you will learn something or get something in return, then it's better just to focus on the skills. And then at the point where you will be doing your posters, your abstracts, your papers, you'll be in a level much higher than any other person at the same stage of career. And that will obviously open up a lot of doors.

Yeah. Well I couldn't have said it better myself. That's incredible advice. Your journey is such an inspiration to me personally, I'm sure to all the people listening. Just a lot of dedication, hard work, one well done step after the other, just building the foundation that you said and then also jumping on the great opportunities that, these foundations the foundation has led you to, whether it was, the initiative that got you that experience at Duke and then also, doing an amazing training as a clinical cardiologist, also doing residency, leaving a good impression, coming to the US for a Timmy fellowship.

I know people here rave about you, and, obviously, that's no surprise. And now I'm so excited for this new phase of your career. Really grateful that, for your friendship. You know, it's, it's been great 2 years here having you in Boston as a friend, as a collaborator, and, best of luck in your career in Brazil. I know it's gonna be amazing.

I'm sure gonna miss you a lot here. Yeah. Thanks, man. It's really been, going beyond the professional aspect. Just being here, having you as a colleague and a friend has been a huge part of our experience here in Boston.

Really great. We really miss you and Carol a lot on a personal level. So that's been terrific. It's a new part, a new stage of our lives. We always move forward.

So it's on one hand, it's always painful to leave behind friends, family, and everything that we've built here and all of the academic opportunities and the city, but at the same time, having the opportunity to build on these foundations and all of these friends and colleagues we leave here, going back to our hometown, to a part of Brazil that has a lot of smart people, a lot of hardworking people, a lot of resources and help, help them get to this next step in developing our own research, answering relevant questions, but doing this building from the foundation that we've had here and obviously collaborating with you and all other folks that we've met here along the way, I'm honestly very excited for this next step as well. So I feel like, doing this interview as you're going back to Brazil, you know, we have a good friend who made this analogy, you know, of, I feel like a similar analogy would be like, oh, interviewing, like, Michael Phelps before he went on to win all those Olympic gold medals, you know, so, you, you're gonna do great things and I feel like such a crucial point of your career and, I'm really excited for you, Andre.

Honestly, I feel like Michael Phelps is interviewing me, but but thanks for that. Alright, guys. That's it. That's the conclusion of this episode of Meta cast. It was such an honor to have Andre Zimmerman here.

Now, if I want to invite you to watch the other, sessions that we've done here in meta cast. You can hear them on whatever, platform you use, to to listen to your podcast. I also want to enjoy invite you to join the Meta Analysis Academy to learn how to get started in the research world. I myself did a different career where I mostly started off by doing systematic reviews and meta analysis, and then went on to do a lot of epidemiologic work and I also am involved in clinical trials, obviously not to the same extent as Andre. So make sure to follow us on Twitter, on Instagram, and, listen to our podcast.

And I hope to see you in a future edition of the Meta Analysis Academy. Andre, thank you so much for being here today. Thank you so much for having