Whilst @Girlymicro is taking a well-earned break buying all her Christmas presents in New York, I’ve been loaned this wonderful platform to discuss all sorts of important matters in science and education.
Recently I’ve been speaking a lot with students of all levels about different opportunities they have in the University environment. Things have changed a lot since my day, it’s not just a BSc then a PhD if you like research. There are so many exciting pathways for students in biological and biomedical sciences to follow, but it can become a bit of a quagmire trying to work out exactly which path you might want to take. I often start the conversation with students describing my own experiences at university and how I came to be in my current role, but increasingly I feel that they are now out of date and just aren’t relevant in the modern system.
It can feel overwhelming when you look at the decisions you have to make when starting university – do you take an iBMS accredited course, should you do a placement in industry or the NHS or maybe a year abroad, how about a Masters by Research degree, and what the heck is an MBio? Where are the best resources and who should you ask? Dusty old lecturers like myself will be able to tell you about the content of the courses, and all about our love of research. But we aren’t going to be able to tell you what doing a placement feels like, if it’s worth spending the money on an MRes or how to choose the right undergraduate course for you. To that end, I have asked some of my most engaging and eloquent students who are completing all sorts of different degree pathways to give us all some insight into what we can gain from the university experience in 2022 rather than, let’s be kind and say, my experiences which were more than a little while ago. And with that I’m going to hand over to reins to their expert hands.
Blog post from Daniel Nash
Who am I to write a blog post about placements?
As a Biomedical Science student on an accredited Biomedical Science course, the obvious path for me was to get myself onto a placement year working in an NHS laboratory to complete my portfolio and finish my degree ready to slot into a lab and begin helping patients. However, throughout my degree I felt this was not the path I wished to take and began feeling research was better suited to who I am. A placement is, I think, regarded as one of the best from to gain experience and improve employability while remaining a student and with all the perks that brings. And so, while looking into my options for getting into research positions and postgraduate degrees, I decided a placement year in another area would be a good idea.
My application process didn’t go amazingly, I don’t mind admitting, but given the competitive nature of placements, I’m still happy I got where I am. I was rejected from every single place I applied except for here, many on the grounds that from my biomed background, I didn’t have the specific skills demonstrated for the labs I applied to. So what placement did I get?
My Placement
I am working as a lab based analysist at Reckitt, specifically working on the Nurofen team, where I work in a lab to investigate and run tests on products across the Nurofen brand range. I have been working here for 2 months as I write this and have to say I have had mixed experiences so far. I know after this short amount of time that working in industry is not for me, but I also appreciate all the things it has and will teach me. The equipment I get to use, the analytical & investigatory techniques I will learn to use, and the independence and team working skills I will develop. All will be invaluable to be as I come out of uni looking for opportunities.
This placement was always going to be a learning curve, disregarding the skills I would learn, coming from Biomedical Science my chemistry knowledge was limited, and yet I landed smack bang in the middle of an analytical chemistry lab for complex drug formulations that I’m learning all the chemistry, toxicology, molecular interactions, analytical techniques, and terminology for. I alluded to before that this wasn’t even my first choice of placement and fighting through all the admin of a drug company at the same time made motivating myself to embrace the role harder than it should have been. but I have to give credit to my supervisor, Chander, for changing my mentality on this. We have weekly one to ones where he really emphasised the importance of using this year to learn take on new challenges and understand what I am doing. It shifted my mindset to try and look around the aspects I didn’t enjoy, and find what I could learn from it.
This is now my focus for the year to learn the skills & chemistry, understand the scientific method, and how the pharmaceutical industry works, better than I did before. Some would argue I should have thought this prior to embarking on a placement but being truthful, I think most people applying for placements know this to a degree but hadn’t internalised it like myself, (or at least need reminding of it when it gets tough as I did).
Aside from the academics
My placement was slightly unique in that there is a large cohort of around 20 students working across teams at the Reckitt R&D site, and so-far good friendships have forged, they have been great people to rely on through the chaotic onboarding stages. and we a placement group will work together on charity events, workshops and the all-important pubs nights throughout the year. I hope these friendships stand the test of time.
I’ve played with toxic chemicals, taken part in development of the newest yet to release medications going, and met some really great people all in the sub 3 months I’ve been here. I have to recommend a placement year or summer long, to anyone in a STEM field or beyond. You can’t beat the experience and growth possibilities it provides.
This week is pretty momentous for me. My boss and mentor of over 18 years officially retires. His name is Dr John Hartley and to be honest he’s a bit of a microbiology legend, so much so we are talking about having a sign up in the IPC office that says ‘what would John do?’. He is a completely different personality type to me, he’s an efficient, detail orientated perfectionist and most of all completely calm. When John is in a meeting he sits there in calm contemplation and then swoops in to ask the one question that cuts right through all the noise, right to the heart of the matter.
John has been my boss from my first day as a trainee Clinical Scientist 18 years ago, when i didn’t even know what S. aureus was, right through till last year when I got my Consultant post and became his replacement as Infection Control Doctor. He has been with me through marriage, deaths, PhD, FRCPath and every other significant career moment and so to say that I’m affected by his going is somewhat of an understatement. So how do we cope when these moments of big change come around and we have to find a new way forward?
Trying to remember I am enough
John is loved by so many people and I have looked up to him for most of my adult life. It is normal therefore that everyone is mourning his moving on, it is almost like we are all grieving the loss of the familiar. I definitely feel this. I also find it hard in another regard, as we all grieve as part of the change there is a lot of understandable discussion about how amazing he is both as a person and in his job. I feel this keenly. I also feel very exposed by it as the person who is stepping into the space he occupied. It plays into all of those aspects of imposter syndrome where you ask ‘am I good enough?’. As I said, we are very different people, John has an eye for details that I just don’t, he is calm and measured whilst I have a tendency to jump first and process everything of the fly. This means that I will never live up to ‘what would John do?’ and still be authentically me. There is therefore the inevitable chain of thought that if John is amazing at his job and I can’t be like John, does that mean that I will never be able to be equally amazing at that job? Am I doomed to mediocrity before I even start? It’s not like I’m a little bit ‘not like John’, the way we interact with the world is quite obviously different and so I’m very obviously not like him in every meeting I have and every interaction I’m involved with. It’s easy therefore to let the self doubt and panic set in.
So how am I managing it? I’m trying to not get too sucked into the John conversations. Not because I don’t think he is truly one of the most inspirational people I’ve ever met, but because for the sake of my sanity I can’t get drawn into comparisons. I’m trying to remember that despite the fact that he has occupied that role for my entire career that his way isn’t the only way of doing things, and that I have to try and play to my own strengths rather than attempting to imitate someone elses. I am also trying to hold onto the fact that at no point in the last year where I have had the role instead of him has anyone questioned my right to be in it, or has he disagreed with any of my decisions when I’ve sat down and chatted them through with him. He has been nothing but supportive of me being in post, and therefore if I’m going to emulate anything it should be the faith that he has in me that I struggle to have in myself.
I don’t have to have all the answers…….yet
John was Infection Control Doctor at my Trust for over 20 years, I have been ICD for 18 months, so what I need to ask myself is ‘am I comparing like with like?’. It’s tempting to benchmark in the moment, it’s tempting to compare how well respected and how established he is against how I feel I’m perceived. The thing is I’m benchmarking in completely the wrong way, I need to be benchmarking against how he was 20+ years ago. Otherwise I’m setting myself an impossible task; I can’t benchmark against him now as I’m setting myself up to fail, and I can’t benchmark against him all that time ago as I don’t have the data. That said, I suspect that Dr Hartley was probably born amazing and so it would be a challenging thing either way. So, should I be benchmarking against him at all? Should I instead be taking the time to reach out to my contemporaries to see how they are feeling and how they are dealing with similar changes?
The other thing that occurs to me whilst I write this post is whether anything has in fact changed, and whether benchmarking is actually the way to go at all. You see, the thing is, I’m not really comparing like with like. John is a Consultant Microbiologist from a traditional medical background, I’m a Healthcare Scientist. I’ve spent my entire career being the only person who was doing quite what I was doing and carving my own path. Why suddenly now that John is leaving am I abandoning the approach that has stood me in good stead and trying to be the same as everyone else, instead of embracing that difference in a way I always have? Why am I so tempting to discard everything that has previously made me, me? The more I question, the more I doubt and so I need to return to embracing my gut and knowing that I am exactly where I always wanted to end up, and stop being so scared that it will all be somehow taken away from me.
Take a leaf out of his book
If I’m not going to benchmark against him, what am I going to do? Well, first things first I’m going to reflect on what it is about him as a boss, a clinician and a leader that makes me and others respect him so much. I want to do this not in order to copy him or compare myself to him, but in order to be inspired by him to be better.
One of the things that John has done for me be, ever since I joined, is that he has championed me in rooms where I wasn’t present or wasn’t invited into. He has never let our difference in professional backgrounds stand as an obstacle to what he thought I could achieve and, when I’ve needed him, he’s fought tooth and nail to guard my corner. He has also sometimes been more honest with me than I could handle in the moment, and never stopped pushing and challenging me to be better than I believed I could be.
No matter what room he has been in John has always been his honest and authentic self, he’s not tried to curry favours, he’s not tried to manipulate or play power games. He has always gone into every room with both his staff and his patients at the centre of his decision making. The ability he has therefore demonstrated to handle conflict and disagreement is something that I can but admire. He’s not scared of being the lone voice in a room if he believes that he is doing it to give a voice to others.
All of these things are things that I want to do, want to be better at and strive towards every day. There will be times when I don’t achieve them, but by using him as a continued source of inspiration, rather than a benchmarking tool I use to beat myself up, I hope to become a better version of myself rather than a shadow of John.
Find my new allies
One of the other actions I’ve realised will be important for me in moving forward is be proactive in identifying new mentors and allies. People who will push and support me in being brave, and in standing up for both myself and others. Losing a keystone of your network and support mechanisms is always jarring, but it is also an opportunity to evaluate what your needs are now, and where you need to develop your networks further for the fresh challenges ahead of you. Finding mentors is often a fortunate accident, but there are also times when you need to actively seek out those people who will be able to help in any new phase of your career.
I’m also beginning to realise that I need to maximise my horizontal networks as well as looking upward for improved learning and guidance from those ahead of me. I’ve always found peer support like this organically, but I think the time has come to undertake deliberate action and to actively invest resources into it. This has been of great benefit in my role as Lead Healthcare Scientist but isn’t something I’ve attempted so much in my clinical role, partly because I suspect I’ve been too comfortable and had such great existing support. I have plenty of connections in this area, but turning those connections into something more requires time and the building up of trust and shared experiences.
I will have different battles and different challenges
Firming up networks and identifying new sources of support is important as well because I think the challenges ahead of me are going to be different to the challenges I’ve already faced. John has done an amazing job of leading the way and has built excellent foundations for me to stand upon, but the world of healthcare has changed so much in the 20+ years he’s been in post, and it would be naive of me to think it won’t continue to fluctuate. All of this means that if I am going to be able to tackle these new challenges and prepare for a dynamic future, I can’t just rely on what has been before. I need to have my toolbox ready to enable me to deal with what lies ahead, and a really important part of that is making sure that I have people around me who will challenge my thinking and inspire new ideas. If we want to create real change and improvement we have to be prepared to take a leap into the unknown. Sometimes this is helped if you have people around you who are both supportive but who can als give you a little push to get over any hesitancy. Although, in my case, it’s more likely they may need to stop me gambolling down the road with too much alacrity. Finding your tribe has always and will continue to be important to me.
Perhaps one of the reasons I find this all so hard is that the reality is hitting me that I’m no longer the new kid on the block. I’m no longer the young whippersnapper who is coming in and seeing the world in a completely different way. I myself am becoming the old guard, I’m becoming the person who has been somewhere long enough to harken back to different times when things weren’t the same. This presents a lot of cognitive dissonance when at the same point you still feel like you are new and haven’t quite got a handle on things. Just merely realising this helps, it helps to see the strength in where I’m at. I am still young, I am still new, and the position is novel enough to me that I can see 101 ways where I would like to grow it and me for (fingers crossed) the better. I have also been in the Trust for long enough that I know how things work, I know who to speak to, I know where the barriers and opportunities might be. If you look at it in this light, I am in the best possible position to embrace what is to come. So, although I am still grieving the loss of the past, I am beginning to be excited about the future.
Dr Walker is a paid up member of the Dream Team since 2013, token immunologist and occasional defector from the Immunology Mafia. Registered Clinical Scientist in Immunology with a background in genetics (PhD), microbiology and immunology (MSc), biological sciences (mBiolSci), education (PgCert) and indecisiveness (everything else). Now a Senior Lecturer in Immunology at University of Lincoln.
Those of you who know me know I have a serious problem saying no to any outreach activity, even when it falls well outside the very tiny limits of my comfort zone. My science family have persuaded me to run schools’ days, science clubs for toddlers, blog posts and even the odd science stand-up comedy night. It’s not that I am an extrovert, quite the opposite is true, I am the quintessential laboratory nerd. I like analysing data, planning experiments and some quiet time with my beloved flow cytometer. However, I know the power of outreach and I only need look to the inspirational scientists who came before me, and took the time to speak with me when I was young, to justify pushing myself outside the comfort of my lab and into the spotlight again. And to be clear. I really love my lab.
So during the summer break my good friend, colleague and mentor @girlymicro picked up the phone and asked how I felt about coming to help support a ‘little event’ she had planned. As I’ve said before, one of the most charming features of @girlmicro is that she rarely recognises what a big deal she is, nor indeed that what she considers a ‘little event’ is most peoples idea of a very BIG deal. Now @girlymicro knows all my weak spots. She knows I love a bit of outreach, she knows I love working with children, she knows I love the drama of the theatre and, more than all this, she knows I absolutely adore baking and harbour an intensely secret desire to be a professional pâtissier one day. ‘It’ll be a wonderful day’, she said, ‘an intimate event celebrating healthcare scientists – you wouldn’t mind baking a cake or two would you?’. I had already said yes and was thinking about recipes when it occurred to me, I hadn’t asked about the venue or numbers, or really anything at all.
Of course, the event was the Bloomsbury Festival(!) and a couple of cakes was a free afternoon tea for all comers. For those of you who don’t know, and perhaps didn’t attend, the Bloomsbury Festival is an annual celebration of the area’s creativity which each year presents an inspiring programme of culture, arts, science, literature, performance, discussion and debate. It is, by anybody’s estimation, a very big deal. And what a wonderful day we had.
The inimitable Nichola Baldwin of Project Nosocomial lead us through three really outstanding performances. Remember, Remember – the amazing *true* story of how three healthcare scientists set out to foil the gun powder plot with help from 9-year-old Princess Elizabeth. For me, this show always delights. The children, and adults, in the audience loved it fuelled by their complementary @girlymicro branded cupcakes. Nichola and @Girlymicro showcased a new play – ‘All opinions are my own’, a powerful performance based on this very blog. I can say truthfully there wasn’t a dry eye in the house. We laugh, we cried, we had a marvellous afternoon tea, and we used voguing to demonstrate the importance of the T zone in appropriate mask wearing. Finally, when the heavens opened and we were sure no one would brave the rain to come to our last session, Nichola and @Girlymicro closed the day with a performance of ‘Mrs X and Me: What is AMR and What can we do about it?’. Despite the rain, the superb actors and healthcare scientists performed to a full house and everyone left truly understanding the looming health crisis of antimicrobial resistance and how we can all play a role in preventing it.
I can’t think of a more appropriate way to celebrate the incredible work Elaine does in science outreach and communication than an afternoon of theatre celebrating healthcare scientists with tea and cake. And now I have my Food Hygiene and Safety for Catering certificates – I might even be persuaded to run another one.
Filmed content linked to the Nosocomial Project can be found here on the Rise of the Resistance YouTube channel.
I’m going to tell you a truth that might shock you……..I don’t like Yorkshire Tea (my family may disown me as Bolton Upon Dearne is in my blood). I don’t even really like fruit tea. I have a tea ranking system:
Darjeeling
Lady Grey
Earl Grey
Jasmine (preferably flowering)
You’ll probably be looking at this and thinking why on earth is she telling me this. Well, the reason is if I am this picky about my tea is it any surprise that I am not everyone’s favourite person. If I’m this picky about tea, other people are bound to be this picky about other things, including people.
You are not going to be able to convince me to take my tea strong and with milk instead of weak, black, and with lemon at a push. I’m equally unlikely to convince you that I am someone who fits into your world view if you’ve decided that I don’t.
So why do we fight against this simple truth so hard?
For a very long time, I’m talking decades of my life here, I thought if I tried hard enough, I could be liked. If I tried to reign in parts of myself with different people, if I tried harder to fit the mould, I would be able to win people over. Now I’m into my 4th decade I realise there are some fundamental flaws to this way of thinking:
It assumes you have to be liked to suceed or to work with someone on a project
It diminshes the strength of difference
It assumes being a lesser version of you will be better, without acknowledging that being inauthentic has other downsides
It only works if you can do something to control the behavioural response of another person, in all likelihood a flawed concept
It starts out from a point of thinking there is something wrong with me
Winning personality
So where does this flawed thinking come from? I think we are told as children, whether explicitly or not, that if we behave well enough and fit into societal expectations then we will be liked, we will be popular as a reward and we will succeed. The reality is that it doesn’t matter how much you smile, how much effort you make, sometimes you will encounter people whose world view is just different to yours. That doesn’t make that person bad, it doesn’t make you wrong or right, just different.
I’ve had professional relationships where it took me years to realise this. Professional relationships where I tied myself in knots trying to make a break through where the other person would suddenly see the value of me. I tried to be less me in order to meet some undefined standard, I tried to hold the line in case they respected strength, I tried praise and engaging in discussion in their topics of choice in order to bond us. It failed, sometimes it failed horribly, because none of those things ‘fixed’ the fact that our fundamental world views, value and beliefs were just never going to reconcile.
Two things about this approach. First, even if it had worked it would only have worked short time, that kind of lack of authenticity to who you are is too difficult to maintain over time and actively harms the way you feel about yourself. Secondly, it was a massive waste of energy and effort. In hindsight I understand now that I would have been better served by understanding that I was never going to be liked, I was never going to have the break through I craved, but instead invest all of that energy and time into learning to find areas where we could work together irrespective of the way we saw the world.
If only I could explain it better
Everyone loves a trier…….err no, no they don’t. One of the things that people like least about me is the fact that I pick up ideas and run with them. I have an idea, become enthusiastic and just crack on with it failing to consider that a) some people are less comfortable with change than I am or b) other people care much more about territories and boundaries than I do, and so me running with my great idea may result in me breaking through other people’s fences.
I used to think that if only I could explain my concept or my idea better then everyone would just get on-board. This just isn’t the reality of the situation. It doesn’t matter how great my plans are, they alone are not going to change how others receive or are impacted by them. Explaining them better isn’t enough. Instead of sulking about the fact that others ‘don’t get it’ I need to work harder to see the whole landscape from the angle of those impacted by my plans. Don’t get me wrong, I’m still not great at this one but I’m at least I’m aware and working on it.
Secretly everyone is like me…..right?
Humans are by their very nature ego centric, as no matter how hard we try we can only truly hear our own thoughts and voices. This can present some really true communication issues where we can come to believe that everyone is like us. I often see my vision of the world so clearly that it can be hard to adjust or even truly realise that others see the world in a completely different way. Your personality, your experiences and your surroundings all work together as a jigsaw puzzle to create the picture you see. The flaw in the thinking is to think that those things all combine in a way that means others will have the same image when they come together as you.
I’ve been slow to realise the truth of this. The things that are fundamental truths in my world are not the same in other people’s. You can’t make the assumption that deep down we are all the same and care about the same things, because we don’t. As healthcare professionals I think I’d always assumed that there were things that we could extrapolate about each other because of our chosen profession, things like patient centred care being at the top of all of our list of drivers. This isn’t true. It took me years to figure it out, but that’s the reality. You can’t shortcut this stuff on the basis of labels, such as job title. This doesn’t mean these other people are bad at their jobs, it doesn’t mean they don’t care about patients, it’s just not necessarily the thing that gets them out of bed every morning. Some of them are there for the intellectual challenge, some are there because they like to lead, and some are there because they enjoy the fulfilment of papers being published etc.
All of this means that if you enter a scenario making assumptions that the drivers are the same and therefore base your success criteria on those assumptions, one or both of you are likely to finish the interaction believing it to be a failure. You also won’t get the most out of those involved, in terms of either engagement or ideas. The power therefore is not in being liked or being the same, the power lies in learning to both identify and work with difference. This means finding areas of overlap where different people can contribute differently, reflecting who they are as people.
You can’t always be what people need you to be
As a leader one of the things I’ve become aware of over recent years in that sometimes you can be disliked because you can’t be the person someone needs in the moment. Leadership is about balancing the needs of everyone, your team, your patients, your service. It’s about being open to opportunities for everyone and ensuring that doors are kept open. Sometimes that means that you have to say ‘not now’ to some people in order to maintain parity of access, as not everyone is able to ask for support in the same way.
I found this to be one of the biggest burdens of being a leader. I like to be liked and I just failed to keep everyone happy. Understanding that sometimes to be fair you have to also be OK with being disliked was a turning point for me. By seeking to be liked I could actually be disadvantaging others and that is a price that is too high to pay, just to make me feel better.
Understanding what is and what is not within your remit of control has really helped me with managing my emotional response to some of these situations. My remit is to try and make transparent decisions which are articulated in terms of both thought process and outcomes. I need to take ownership of that process and ensure that I engage with learning about how to do it better. This involves acknowledging responses to it. What I can’t do it take on board everything that happens emotionally linked to it. I can’t ‘fix’ everything and others are entitled to disagree. I need to take on feedback and turn it into something productive rather than trying to White Knight everything in the hope of changing minds, as in the long term that doesn’t help anyone.
The sooner we realise the truth the better. The sooner we realise the truth then we can understand that working together doesn’t need us to be soul mates or best friends. Our differences will (if we can get over ourselves) likely make our processes better. The sooner we realise this, the sooner we can have open non judgemental discussions about areas of over lap and shared drivers in order to work out where energy and resources will be best place. The sooner we realise this the sooner we will stop putting energy into diminishing who we are to fit some non existent ideal and open the door to liking ourselves that little bit more.
I’m off to have a super weak cup of darjeeling…………please don’t judge me for it
Over the last few years there have been a number of, well let’s be kind and call them learning moments, for me about how life works. I guess I’ve spent my life being pretty naive and thinking that if my evidence was good that was all that was needed to win people over or for my version of ‘good decisions’ to be made. The transition from that to knowing that a lot of decisions are not made due to evidence but due to scenario, relationships and people has been harder than I can properly describe before cocktails. Recent events, including some of the Infection Prevention kickback on social media, has led me to take this post out of my drafts section and forced me to finish it.
My hope is that by putting this out there others will be more prepared than I was for some of the conversations they will inevitably have as leaders down the line.
Know your remit
Just before Christmas last year I walked into a room as ‘the expert’ thinking that my expertise would lead to the outcome which I had deemed to be the most sensible. Worse than that, I hadn’t considered my role in that room before I stepped into it. Usually when I’m in a room I’m there to make decisions, it’s what I spend most of my day doing. My upset therefore when the information I presented was heard but my recommendation was not acted upon was pretty visceral, this was high stakes stuff after all. I hadn’t spent enough time considering my remit before I went in. My remit in that room was as an advisor, it wasn’t as a decision maker. Therefore I had set myself up to fail. I needed to set my success criteria (more on this later) linked to my presentation of information, not about the decision itself.
That day was an object lesson in being an expert in one piece of the puzzle, but not being able to access the whole picture. Not because I hadn’t done my research but because often as advisors and not decision makers in a space we are not given the full picture to understand how the decision is actually being made. This can leave someone, like me, who works based on evidence base and data, feeling lost when a decision is made that appears to contraindicate what we’ve put forward. I find it especially challenging as often I am in the room as a decision maker, and the switch in remit from one to another is not always well defined. Trying to understand what role you are occupying before you enter a space is therefore key to both the outcome and your mental wellbeing.
Sometimes you also need to understand where your remit of influence lies. Something may be happening you don’t agree with but it is not within your remit of influence to change. Knowing when this is the case and acknowledging it means that you are more likely to be able to find a way forward. Can you offer a support role? Is it something that is right for you to be involved with, or do you not have insight or expertise in that area? In which case do you need to upskill or acknowledge your involvement might be unhelpful? If we wade in without being prepared we can make situations worse for those that are actually impacted.
Collect your evidence
Having said that having evidence and information will not always change the outcome it must be acknowledged that without it you have probably lost the battle before even entering the room.
Why is this? Well without information what you are doing is appealing to emotion. This may be a good thing in politics but is unlikely to be a successful approach when you are in a position to influence due to your expertise. Hearts and minds is an important moto for change but the foundation needs to be solid. It could just be the scientist in me, but I want to enter a situation with as much information as I can access to hand so I can flex my argument and respond to challenge and come back with data.
Another thing is that by going in with information you set the expectation that you anticipate data and evidence in response. This can help in situations where you expect to be fobbed off. It can also help in emotive situations, where instead of adding fuel to the fire you are removing the judgement/emotion and presenting just the information to respond to. It can also give a way out to both sides in terms of changing their position. It is a sign of good leadership to acknowledge new information and react to it. Remember this goes both ways however, and so we should also not use evidence that is sub-selected to maintain a dogmatic argument.
Talk to your stakeholders
A key part of gathering your evidence and sense checking your argument is talking to people who are involved. This is important for a number if reasons:
Understand the landscape the decision is being made within
Understand the drivers of the key decision makers, this will help you understand whether the decision is within your sphere of influence
Understand the impacts of the decision, particularly on those you are engaging with
Help you to identify evidence gaps or other holes in your thinking
Help you to identify the potential consequences of speaking up for you and others
Its important when speaking to stakeholders that you speak not just to people who are likely to think the same way as you, this way leads to group think. You need to try and speak to people who are likely to disagree with your position, people who have a more strategic view of the landscape who may be able to tell you what you’re missing, and people who are likely to have influence in the room. The last are particularly key in terms of preparation as you are removing some of the unknowns. Best case, you may win over a decision maker so you know that they will support you, worst case you’ll be able to prepare for what streams of thought they might introduce during discussions.
The most important thing here is that if you are representing others as a leader, that you have spoken to those you represent enough to make sure that you are genuinely reflecting their position and thoughts within the room, not just your own.
Practice your argument
I can’t emphaise this one enough. If you are going into a high stakes meeting you need to practice your argument, preferably with others beforehand. To me there are a few reasons for this:
Identify flaws in your chain of thoughts, or weaknesses that you can address
Work through any emotion linked to what is about to happen before you get into the space
Find the rhythm of what you are going to say, who you will look at when, how you will evaluate how your argument is landing and flex if necessary
These situations are often emotionally charged and for the sake of the outcomes you can rarely let that emotion, be it fear or upset, show. These need to be adult – adult conversations, as the situations are often complex. I found the infographic below, which is aimed at having difficult situations with family, but I think a lot of the questions can help formulate thinking around any difficult/high stakes conversation. Things like starting out by finding common ground are so important, people are much more likely to negotiate once you’ve established similarity. Therefore, practicing structure and order, as well as content, can make all the difference.
Pick the right when and why
No one wants to be the girl who cries wolf, who constantly involves themselves in issues that don’t involve them and become perceived as a meddler, or worse than that…..a drama queen *gasp*. At the same time there are things that you do have to stand up and speak up for, be that for your team, your patients or yourself. Knowing when and why to speak up is therefore key.
Let’s start with the why. Well firstly we’ve covered remit, is it something you have the facts and information about in order to appropriately escalate? Ideally, is this somewhere within your sphere of influence? If not you may be better placed in a support role whilst someone who fulfils the above does the speaking out. There’s also something here about authentic leadership and living your values. It’s not enough to say what your values are but you have to live them and follow through. When these three things align then it is definitely time to act.
The when can be more challenging as there are multiple ways this can play out:
Formal meetings
Informal meetings
1:1 discussions
Email
Public vs private
The right when/where can depend. Challenging bullying behaviour for instance may be best done in the moment but there are times when it might be better to pull the individual to one side to have a private 1:1 first. Some of this depends on what your success criteria look like and so you may not know initially until you’ve decide what it is you are trying to achieve.
Know your success criteria
This is one of those things I should have thought about more before going into the meeting discussed at the start of this post. Success criteria have to somewhat depend on your level of influence and decision making in any situation. In that case I had some influence and no decision making remit, the best I could hope for was to influence the discussion. Therefore basing my mental wellbeing on the outcome was foolish, as I had limited capacity to change the outcome. My success criteria should have been to go in and clearly define the scenario and give my recommendations as eloquently as possible. Then I would have left the room less disillusioned and questioning my role.
Success criteria can look like all kinds of things, depending on the situation:
Influence the decision
Achieve an outcome
Shine a light
Escalate to a more appropriate/different group
Demonstrate support
Achieve a change
Identify support/supporters
Knowing what you are trying to achieve is a key part of developing a strategy and being able to prepare properly. Sometimes we can only achieve a statement of ‘this is not right’, other times you may be able to change an outcome. It is best to be realistic about what the best case scenario actually looks like and aim for that, rather than aiming for something unrealistic and achieving nothing.
Be prepared to pay the piper
#realtalk all of this comes will come with a cost. No one likes the person who is disruptive and speaks out, at least not in my experience. They may respect you for it, but they won’t like you. There have been times when I have sat down and had serious conversations with myself about whether I am prepared to live with the consequences. I’m usually more sure of myself when I’m advocating for others rather than for myself, as that usually aligns so strongly with my values. The times I’ve had to step up and advocate for myself have been both hard and terrifying. When I have conversations with people about advocating for others, I tell them I see it as part of the job. I am here as a leader, I am here to represent my workforce, I am paid to quite literally ‘take one for the team’ on occasion. If I then have to manage the fact that I am not always well liked for giving a voice to others that is a price I decided I was willing to pay before I took the job. If I ever feel like I don’t have it in me to pay that price then that is the time I need to reconsider whether I can fulfil the job role that I am in. The role is too important to not do it well, to not step up and advocate for others. If you can’t stand the heat then it’s time to get out of the kitchen.
Be bold, be brave
So here is the truth of the matter, speaking up requires you to be brave and be bold. It requires you to put your head above the parapet for the benefit of others, even if it comes at a personal cost to you. It’s worth it because you are living your values, it’s worth it because you are advocating for change and for the benefit of others. No matter the cost to you the impact you will have will out way it. It’s in these moments we know who we really are, especially when we fail. That said, all of it can be easier if you do the work beforehand to understand what you advocating for, so you have the data to back your arguments and to ensure that you are the right person to be in the room waving the flag. We are all much braver than we think and we are many, so reach out to those who will you hold you up and support you in speaking out for those that don’t have a voice without you.
Shortly after I was 14 I went for tea with my Great Aunt. I had long black hair (I was a goth for over a decade) and when I went into her house and we were away from the street she started to berate me: my hair was down, it wasn’t up, it wasn’t dressed. I was 14 now, I was a woman, what would people think if I wore my hair down. People would question what kind of woman I was, how would I get a husband? who would look after me? If I didn’t dress properly, learn to cook and clean and behave properly no one would want me.
Needless to say, this probably had the opposite of any intended effect I pointed out that I would wear my hair how I wished and that I didn’t ‘need a man to take care of me’ and that I ‘was jolly well able to take care of myself’. Thus was my first introduction to how the way I dressed would be used to judge both me, and my current and future potential for success. This was only emphasised further at my girls school, where being a goth was treated as a one way street to failure at life, rather than a means of self expression. Like applying black lipstick or having black hair would immediately consign me to the rubbish heap of life. I continued to wear black lipstick and have black hair far into my 20’s in part to prove that their expectations were nonsense.
Imagine my surprise then to find, when working at a council as my first job post university, to hear one of the inspiring female leaders there spending her time preaching a similar message. I remember her so clearly 20 years later, even though I don’t remember her name. She was very senior in the council and was on her way to Westminster to speak. I noticed that she always wore trouser suits with small shoulder pads and so I asked her whether she wore them as she felt more comfortable or empowered in them. She replied she didn’t even like them, but she’d long ago learnt that she had to dress like the men in order to succeed or be taken seriously. No long hair, no skirts, you must have makeup but it must be natural etc.
That’s politics you say, in healthcare we meet patients from all walks of life and therefore we should be able to represent ourselves and reflect back at them that same sense of diversity………….Well that is what I’ve always thought too. Until I went on my first senior leadership course run by the King’s Fund. Now this course was so hilarious in so many ways that at some point I will write a separate blog entitled ‘Taking a walk with the wheel of my life’ but for now let me share that it was the worst £9000 I have ever spent.
The course was called the Athena programme and was specifically aimed at women in senior leadership positions in healthcare. The first three day retreat involved many horrors that occurred within a monastery with no phone reception or Internet access. On the second evening there there was a three hour session on dressing for success. As part of this I was made to endure an extensive slide presentation showing that successful female leaders all wear ‘a uniform’. The uniform being a box jacket, skirt suit, chunky statement necklace and a broach. They included a picture of Margaret Thatcher and the epitome of ‘the uniform’. At this point I should have collected my things and left but as £9000 is a lot of money and I have a thing for certificates, so I stuck it out for the whole 4 modules over a year.
Why am I so offended by this?
The fact that I go by Girlymicro has probably not passed you by. In 2012 when I setting up my twitter account the name was fairly deliberately chosen. I was surrounded by successful men but I hadn’t really met any senior women that I could access for mentorship (thankfully that has now changed and I know loads). I was saddened by the continuous messaging that I needed to be someone other than who I was if I ever wanted to succeed. It wasn’t good enough to be smart, it wasn’t good enough to be driven, it wasn’t good enough to succeed at the tick boxes, instead I had to look the right way to have doors opened for me. This went one of two ways, I could be ‘the pretty one’ where doors could be opened as I was appealing to men, or I could be ‘one of the guys’ where I was accepted because I tried to be one of them, look like one of them, behave or talk like one of them.
Well sadly most days you’re lucky if I get out of bed and brush my hair, so I was never going to be one of the pretty ones. That said I don’t wear trousers, I like kooky shoes and maxi dresses, I’m not being caught dead wearing a statement necklace and you don’t have enough money to make me cut my hair. I am not therefore ever going to be one of the guys. So where did that leave someone like me? Destined to be pretty much invisible as I didn’t fit the mould? Screw that, it left me making a deliberate decision to try to break that mould by just being me, as publicly as possible. Choosing Girlymicro as my twitter handle was the first step in this journey.
Does this mean I’m saying wear what you want?
Let’s get this one out of the way, I’m not advocating you turn up to clinic naked or in a bikini. What I am saying is that you can be both respectful and wear clothes that represent who you are as a person rather than being forced to conform to a standard set by ‘others’.
I really believe that dress is one of those things where we use it judge whether people fit our cultural norms. If someone doesn’t fit then no matter how good they are at the role it will always be a challenge. I’ve lost count of the number of times it’s been made clear to me that if I only fit in more, played the game more that I would go further. Dress is just one example of how this is acted out in a way that it easy to assess.
Why is all of this important?
All of this matters because we don’t sit in isolation from our patients, or from our students. We are the people that stand in front of them. This may be why you tell me that I need to dress a certain way, but is it really?
Is dressing a certain way actually only a reflection of an older version of healthcare where it was about clinician authority? If we are moving towards a model of healthcare that is more based in co-creation isn’t it actually more important that our patients and trainees see diversity and representation in us that reflects them?
I think this is also especially important when we’re talking about progression and recruitment. If people can’t see themselves in a position they will often discount the fact that it is for them. Dressing in ‘the uniform’ isn’t just exclusive in terms of making in and out crowds visible. It also requires privilege. None of those clothing items are cheap, most of them would have been incredibly inaccessible to me until I was on a consultant salary. To be honest even now I’m on a consultant salary there are things I would rather spend my money on. Why are we making a job that is already difficult to access and viewed as inaccessible even harder, by requiring you have have money to merely fit in.
My other question is whether this reflects our diversity and inclusion aspirations? Where do braids fit into this or choosing to wear a hijab? What about those people who have alopecia or are allergic to make up? If we are serious about representation and moving towards a more inclusive working environment should we be setting implicit standards which require others to change who they are in order to conform if they wish to succeed? What kind of message are we sending about what we require to work with us, if we are saying you have to leave who you are at the entry of where you work.
Wear what empowers you!
I am always going to be the kind of person who looks like they’ve walked through a hedge on the way to work and if I manage 3 hours without dropping food or drink down myself it’s probably because I haven’t found time to have either. This is what I’ve landed on however. I will wear things that empower me. Some days that means I may wear a jacket, sometimes that means I will wear an inspirational slogan and sometimes it just means that I will wear something comfortable that will get me through the day.
I will also not judge the clothing of those who work around or for me. If you are wearing jeans in the lab I do not care. The only place you will receive judgement from me on the matter of dress is if you are working on a clinical unit and are covered with bangles and other things that mean you are increasing transmission risk to others. Even my ‘you do you’ attitude has limits when it comes to patient safety.
I want to finish however with a story that shows that you don’t need to conform to be a success. Many of you will know Dr Kerrie Davies. If you don’t she’s a truly inspirational woman, and don’t just believe me, she won last years Healthcare Scientist of the year award from the CSO, so people who are waaaaaay more senior and brighter than me agree.
I met Kerrie when we were both trainee Clinical Scientists over 10 years ago. Since then she’s won million pound grants, been a Lead Scientific Advisor for the UKHSA during the COVID-19 pandemic and been awarded a PhD. All with blue hair! Kerrie expresses who she is and is unapologetic about it, whilst simultaneously being both a super bright and empathetic leader. All I can say is that we should all ‘be more Kerrie’ and the world would be a better place.
Whilst you think about your outfit for tomorrow and how you are going to start wearing something that will help you be just a little bit more you, I’m off to have a serious think about whether I could pull off blue hair.
It’s that time of year again and many of us will be taking on new trainees, getting to know new students or supervising new PhDs. I thought it was time therefore to share something that I’ve found increasingly useful and have now set out to cover in initial meetings with learners, and that is the development of learning agreements.
What is a learning agreement and why is taking this time worth while? Surely everyone knows what they’ve signed up for when they take a training place? The truth of the matter is that students often know the logistics of what they’ve signed up for, but any learning placement is a whole lot more than just the nuts of bolts of the curriculum. There’s a lot of expectation setting/management required for one thing. We’ll cover what learning agreements look like in a bit, but in short they are agreements based on conversations between the learner and their supervisor where they actively set out the expectations and boundaries of their relationship.
At STP/HSST and PhD level it can be the learners first experience of formal education routes within a professional setting. As supervisors we often expect learners to be able to undertake independent study at this point, identifying their own learning objectives and being responsible for any escalations. If this is the students first experience however, they may believe it will follow the pattern of the prior learning they have experienced, which may have placed a lot more focus on structure and consistency.
What is a learning agreement?
In light of these complexities what is a learning agreement and how can it help? Well they take quite a few different forms depending on what it is that you want them to fulfil. In short they are a working (and therefore dynamic) agreement between you as the supervisor/education officer and your new student/trainee. I tend to refer to them as learning agreements rather than contracts as the term contract to me implies penalties and learning contracts are what I escalate to if challenges occur during the time someone is with me.
They can include all kinds of things:
What topics are in or out of the learning objectives
How deadlines will be set and a broad plan of work
Expectation setting around students identifying additional learning objectives
Ideas for how the learner will benchmark their progress and/or learning
How the educator will assess progress/learning
Although the above is often the framework the most valuable parts of a learning agreement for me are less structural. It is my time to ask:
What kind of learner are you?
What kind of support do you prefer (close vs supportive supervision)
What are your main objectives that may or may not be topic based?
What are you hoping this will lead to?
How do you prefer to communicate, face to face, email etc?
Why this course? Why this training? What attracted you? In order to understand their drivers
Making the implicit explicit
In general I think most of us are good about talking about the nuts and bolts of what a course/placement entails. We are good at giving the ‘this is the bathroom’ tour and ‘this is where your desk is’ plus ‘our supervisor meetings are on Tuesday’ type of information. What I have discovered over the last few years however, is that imparting curriculum or logistic based information just isn’t enough to support a good supervisor-learner relationship, where both get what they want out of it.
I think as supervisors we have quite a lot of expectations that we don’t necessarily voice, after all for many of us this is something we do a lot of. It can therefore be easy to make assumptions about the level of awareness of these expectations from someone coming into that supervisor-learner relationship with us. The thing is, you may have been doing this a loooooong time, but your learner almost definitely hasn’t. They won’t have that implicit and often organisational linked cultural knowledge that you have been embedded in for so long. Worse than that even, they are likely to have a whole lot of different assumptions based on their last educational experience that they are bringing with them. Unless we all work therefore to make things that we implicitly understand explicit, you won’t know where those differences in practices and expectations lie. It is when this happens that problems often occur that could easily have been addressed early on, but have significant impacts on learner experience and supervisor stress levels.
Supports orientation to a new field/culture
As I’ve said a few times culture matters, as culture and cultural norms are intrinsically linked with the expectations we all have. Having these conversations is about more than expectation management however. Learners are coming into an environment that may be pretty alien to them. This can make students feel like they are floundering, right from the start, meaning that they don’t feel like they fit. A small percentage of students are likely to walk away because of this, not really understanding the cause. This is often combined and amplified by the fact that they may have moved or lost their support networks in the transition.
Talking about your role (and similar roles) with learners helps, not only to build your relationship and set expectations, but also to support them in making the transition into being a scientist in practice, not just in name. It took me years to feel like a scientist, to feel comfortable calling myself that, to feel like I belonged. Having conversations where students understand what it takes to succeed as a scientist, not just in a placement, can be invaluable to learners re-establishing support networks. Also, supporting learners to find other trainee groups, to join twitter, or of timings for lunch clubs, can help them settle into their new role and their future profession.
Setting matters
Having these conversations can feel uncomfortable and challenging, mostly because of the fear of the unknown. They may also take time we may not have. All of these are reasons to make sure they are done correctly and given the time required. If you are nervous having them with your learner then imagine how nervous they may be to have them with you. You are asking for a lot of honesty and self reflection from someone who doesn’t know you well, in a relationship where trust may not yet have been built. Furthermore, you are asking for all of this in a relationship where you probably have all the power and where your learner is likely to be highly keen to please, rather than representing their true self..
So how do we hold these conversations and support them getting the best outcomes? I think there a couple of things we can be mindful of. The first is not dropping them on the learner. If we want the conversation to deliver we both need to do the work. I need to be honest with myself about time and also what kind of supervisor I am. The student needs to be given the questions or a framework beforehand and supported to have time to reflect on themselves to be able to answer the questions asked. They may need to be encouraged to speak to friends or family to support them in this reflection if they’ve never done it before. They can then start the process of reflection by thinking in the presence of people they trust, if needed.
Think about where you physically want to have the conversation. I tend to take learners out, to a none Trust space where we can have tea and cake (or other suitable consumables). I’ve written before about the power of tea. The main reason that I do this is that it means we are no ones turf, we are in a neutral space, and the provision of food further helps to reduce/remove hierarchy. When thinking about where however, you need to consider privacy. Your learner may need to share things that are private or important to them, and so considering the type of location is also important.
The other important thing about getting the conversation right is setting the conversational scene before you start the conversation itself. You need to be clear about the objectives that you want to achieve, why they are helpful to both parties and set some ground rules. It’s key to say that honesty is the most important part of this process. It’s OK to have styles that don’t match, by knowing this early you can sign post and find additional support to ensure that the learning process itself still works.
What happens when the expectations don’t match
Hopefully by going through the process of creating a learning agreement you will avoid any significant bumps along the way later on. The process needs to be done thoroughly though, so you don’t just hear what you’d like to hear. As stated above it’s ok to have areas of difference, it’s what you can flex in response to that information and how you respond that matters.
For example, I am never going to be a good micro manager, I have neither the time or personal inclination to work this way. I have fallen foul of not having had the learning agreement conversation and subsequently had learners who felt they were inadequately supported. If I find out that I have a learner who feels they need close support I need to therefore make some pragmatic choices. Is it they will need close guidance for the transition period? If so I can likely change my style for a period of a couple of months in order to support that orientation to a new location. Is it that this is their learning style long term? In this case I need to think about pairing them up or seeking support from a colleague who is better able to provide that close support during the periods in between our catch up sessions.
I have also struggled previously with learners who have not met the outputs that I had expected. This may be more of an issue with PhD students, but to be honest if I’m not clear about publication expectations how will they know? Therefore if it becomes apparent that the timeline expectations don’t match it is worth considering drawing up a broad, high level, delivery plan so you are both working towards the same mental models
Finally, it may be that learners make it clear that they have pastoral care expectations that you may or may not be able to support. Prior to going into these sessions it is important to be aware of the different additional support services that learners have available to them. Whether they need them or not in the moment it is crucial that you sign post to these, especially if you are not the kind of supervisor who will take on this kind of support role. Additionally, there are likely to be plenty of networks that offer peer support that you can sign post learners to. There will always be things that they want to talk about that they won’t want to talk to you about. Let’s be honest, no matter how well you get on there will be times they need to moan about you as a minimum. Being open about this being OK and linking them into peer groups can be incredibly valuable
No matter what you hear in this space it’s important to be open and judgement free, in order to support honest sharing. If you hear something you don’t agree with it’s important to take a beat and try to understand the drivers of that view point. By being open to opinion and challenge now you are investing in success later on. I don’t know about anyone else but I studied in a different time, my undergraduate degree finished 20 years ago. My expectations of learners and learner experience therefore is, to be frank, well old. I’ve also worked in one place for 18 years. It is naïve therefore to believe my experience and expectations are going to perfectly match the learners who are coming through now.
There is a big difference between being someone’s educational supervisor and someone’s manager. In some cases we are both, but we need to understand that they are different roles with different requirements on both sides, and be aware of what hat we are wearing when. Techniques such as learning agreements can help make sure that we do the ‘education’ part better by having the kinds of conversations you would not have with someone you just had a managerial relationship with. It encourages self reflection, expectation management and consensus forming. All of which are skills that we should be modelling for those learners we are supporting. If you don’t ask, you’ll never know. So let’s start this new academic year by having conversations better and talking about how we can all be the best we can be.
Its 6am and I’m sitting listening to fire alarms go off in my hotel room at FIS/HIS. I’ve been up since just before 3 in a shame spiral of all the stupid things I said during day one of the conference and only just got back to sleep at gone 5am when the alarms started sounding. Frankly this feels like a metaphor for how my life has felt for the last 2 years, long and short the constant sound is exhausting and stressful. An hour later the alarms are still going and I’m now doing the only thing possible, which is to leave my room in some highly elegant nightwear and take myself, a laptop and a cup of tea to sit in reception to write. I may be looking a humiliating level of baggy eyed exhausted shell but at least it quieter and I have caffeine; which brings this metaphor all the way up to 2022. It’s better, I’m happier but oh lordy am I still broken. So as we sit in our 3rd year of dealing with the pandemic how are things different and how are they the same?
The things I love doing are so close to being back
One of the things that is currently saving my mental health and well being is that you can almost now envision the point where normality could return, or the new normal anyway. I know that if you have listened to politicians and social commentators recently you would think that normal is already here, but for me we’re not there yet. I can however do things like think about booking tickets for the future events (I cannot wait for Eurovision!) and hope they will go ahead, I’m contemplating planning trips and have started seeing friends in slightly less controlled ways. I’m even sitting here typing this at an in person conference, which has been surprising lovely and not stressed me out in the way I thought it would.
This being able to vision is important to me, it’s also important to me in the day job. For a long time all there was was SARS CoV2, you couldn’t plan, you couldn’t see a time when you would be able to do anything else. Now though things that give me so much joy in terms of education and research are coming back, papers are being drafted, grants are going in. I can see that we can begin to focus on other things with changes and improvements that need to happen. It may still feel like a shock but after all healthcare is NOT all about respiratory viruses and there are things beyond that which impact patient care that we need to take some time to focus on as well. All this said however, I have to re-state how tired I am and it is yet to be seen whether I have the inner resources to hit the ground running in the way that I would like.
Back on the carousel
Having just said how happy I am to be getting back to doing some of the ‘normal’ work of Infection Prevention and Control, there’s no getting away from the elephant in the room. We’re still dealing with a global pandemic, which a lot of the world seems to have forgotten. We’re still managing guidance changes, testing cases, investigating and managing hospital cases, but now with all of the funding support withdrawn and whilst being expected to also manage ‘business as usual’ on top of everything else. All that with having had 2 years of no sleep and no rest. In some ways, and this could be me, everything else is also more of a mess as we’ve been in crisis mode for so long. It’s not even as if the ‘business as usual’ is straight forward no even taking into account how much re-training needs to be undertaken.
Because of all of this sometimes it’s hard to tell whether you are on a nice gentle carousel or are actually on the waltzers, trying to manage everything thrown at you in a landscape that is still constantly changing it’s priorities and demanding responsiveness to everything that is being put in front of you.
Single interventions don’t work
Everyone in the world still appears to be an expert in IPC and there still seems to be so much reductionism linked to the idea that a single change will revolutionise everything. I’m a little ‘over’ trying to have the discussion with people that covers the fact that almost all IPC is about introducing packages of measures/interventions. It’s what is often frustrating as a researcher, in that single interventions are therefore quite difficult to evaluate for their impact, but the world we live in clinically requires us to be able to control multiple risks and therefore manage multiple risk mitigation strategies simultaneously. The truth of the matter is that a single change will rarely control risk in the complex environments that our patients are in, even without adding the complexities of human behaviours and human interactions. I’ve written about this before, but I strongly believe we need to become comfortable with complexity and that part of our role in IPC is to assimilate complex multicomponent information, process it to make a balanced risk based set of decisions to establish a strategy, and then to implement that strategy in a way that appears simple and practical to those that are implementing. Taking the complex and processing it so that it can be disseminated in an accessible way is, I believe, one of the key talents of many IPC teams. We need to communicate this better as being one of our strengths and move away from single intervention focuses.
Could do with a little less ‘interesting’
I don’t know about anyone else but i could do with less (take your pick) of monkeypox/lassa fever/polio/Burkholderia/invasive Group A Strep or any of the other ‘interesting’ alerts that we have had lately. I would normally love something novel to get my teeth into, but right now the ‘interesting’ seem to be coming thick and fast and I for one am only just managing getting back to MRSA and resistant Gram negatives. The constant ‘organism of the week’ just means that any return to balance feels like it’s going to be slow coming. I hate routine, it’s one of the reason I got into IPC, but even I could do with a little routine and boring for a while to find my centre and recover a little and recharge those batteries before embarking on the next new thing.
Summer down time isn’t so quiet
I think this has all been compounded by everything that has happened over spring/summer. Summer is usually the time in IPC where you can catch your breath a little, where you can plan for the inevitable challenges of winter and do the visioning piece to work out how you want to develop the service and move it forward so that everything works just a little better. This summer though there’s been little to no respite really, between new variants and waves earlier in the year and the new and ‘interesting’ since. Summer has been anything but quiet. This means that you know you are going to go into, what is predicted to be, a difficult winter without catching your breath and still trying to spin plates, with even more work having been pushed back to 2023. I think we will all still pull it off and I truly believe we will manage most of the things we were all hoping to achieve during the summer lull, I just fear that to make that happen we will carry ourselves into another winter running on empty. I think therefore we need to have the conversation with ourselves now about being kind, not just to other people but also to ourselves, and where you can plan accordingly.
Do more with less
All of this comes at a time when we are all very aware of the pressures on services and the resource limitation issues we are all facing. We can’t just do the same with less but we have to do more with less. The COVID-19 money has gone, the extra staffing support linked to it has gone, but a lot of that work hasn’t disappeared as we are all playing catch up on waiting lists and clinical work. It is easy therefore to feel pretty disheartened about the hill we need to climb, having already given up so much, both as individuals and as a collective.
The truth of this however is that some of the very pressures that sometimes feel like they are crushing us are also bringing some benefits. I am closer to my team than I’ve ever been. I’m more certain of the things that matter to both me and my service. I have significantly more clarity than I’ve ever had before both about my professional and personal life. Limitations on resource access have meant that we’ve had to worked harder to develop networks and build connections in order to use what we have better, and that connectivity has other benefits. So as much as I hate the words ‘better value’ I can see both sides of the coin, and not just about the money. I can see that it will make how we move forward better as we will move forward more together than we have ever been before.
The inevitable post mortem
One of the things that struck me when I went through my first pandemic, swine flu in 2009, was the way that you could do nothing right for doing wrong. One minute you are heroes and the next you are villains because it’s politically expedient and someone has to be the focus of dissent. I know people that were upset by headlines during the Tory leadership contest that basically went after many of us who had stepped up on top of our standard roles to offer help and support. We stepped up because we felt it was the right thing to do and despite (in many cases) significant personal cost. Sadly, having been here before i was not surprised. Worse than that, I think we need to prepare for the fact that this will be the theme over the next 12 to 24 months, and that we will be used as a political football by many people. Hindsight is 20:20 and retrospective data analysis is a very different beast to prospective decision making. So my advice on this one is that we all need to develop a thick skin, understand what the drivers are for the headlines, and let it wash over you rather than taking it as the personal attack it can sometimes appear to be.
So having said all of this what do I think the next few months will hold? I think we will continue to be challenged, both in terms of the patients that present in front of us and in managing the service demands this places upon us. I do think that IPC teams and healthcare professionals will continue to step up and do what needs to be done to make care happen. As leaders however, we need to be aware of what that ask looks like and have strategies for managing it in an already tired work force. For me being able to focus on the future is how I get through the present, therefore planning for normal times is key to my survival. People ask how I’m putting in grants, drafting papers and planning change. I do it not because I have time and capacity, I do it because I have no other choice. I’m aware that it’s key to my survival, to keeping me grounded and enabling me to cope with the stress that exists in the now. Some people ostrich, I plan. As people are different however, I also know that my planning can stress others and so I try to be aware of how much I talk about the future to those people who are opposite and survive by living in the present. Dealing in the best way possible right now is mostly about knowing who you are. The clarity provided by the last two years of the pandemic has helped me in this by forcing me to know more about who I am and how best to manage myself. I have learnt and I hope to continue to use this learning to grow. So I will continue to hit the day dream button and drink tea……….I hope you find a way that works for you.
I’ve sat my fair share of viva voce exams in my time and I must admit I’ve always been pretty intimidated by them, that said they’ve never been as bad as I feared when I finally got in the room. They’ve been on my mind this week as one of my PhD students is due to have her viva on Friday and so I thought I would write down my top tips in order to bring your best self to the process. This post focusses a lot on PhD viva’s but I think a lot of the principles can be extrapolated to other types of oral exams.
1 – Do your prep
Some people think that the viva process is about what happens in the room. Although you have to ‘bring it’ during the discussion your life can be made much much easier by doing a good job in the prep phase.
If you are having a viva for a PhD this goes all the way back to researching the administrative side of the process and being actively involved in examiner selection. In an ideal world your supervisor would sit with you, talk you through the stages and actively involve you in the discussions, we both know however that the world isn’t always that ideal and you may have to be prepared to do this leg work for yourself.
There are some benefits to owning this phase of the work. For my PhD there was a communication breakdown towards the end and my supervisor wanted me to delay submitting for another year and therefore refused to sign the submission paperwork. I knew that I needed to submit on my current time scale as I wanted to sit FRCPath in my NIHR funded time. I also knew because I’d spent time researching the administrative side of things that I wasn’t required to have sign off, that part just meant that UCL weren’t responsible for any failures. So I submitted anyway and passed. I also researched, found and submitted my examiner paperwork and choices.
The downside to selecting your own examiners without supervisor support is that you run the risk of only selecting based on academic publications or area of interest. I was fortunate as I personally knew plenty of people in the field of IPC and so could select with greater context. If you only select on the basis of publications you can end up with an unbalanced panel or one that doesn’t support you to have a discussion that really represents you or your work to the best of your ability. So if you are in a position where you need to lead on this make sure you also find out what kind of examiner they are, and whether there are any political conflicts of interest before making a final decision.
2 – Have a practice
Whatever your situation it is always worth having a practice viva, preferably with people that scare you just a little. Ask that amazing post doc who has always been a little intimidating or the person that always asks good but challenging questions at lab meetings. You don’t want to destroy your shaky confidence at this point but if set yourself a challenge you will amazed at how much easier it is when you are in the room for the real thing.
One of my other PhD students had their upgrade recently and his other supervisor and I ran a mock. Now I apparently can get a little intense when I’m asking questions about science and very rarely I’ve been called ‘the destroyer’ when it comes to challenging the science presented by reps if I’ve found it to be misleading. It was therefore reported back that if you can survive a mock with me the actual event will be a walk in the park. I don’t know if that’s true, but what I do know is that if you have a relationship with your supervisor that permits this kind of mock session, your supervisor will know the strengths and weaknesses of your project intimately. They will therefore be able to ask ALL the questions that you hope your real examiners will skip over or not pick up on. The purpose of us asking these questions is not to discredit what you’ve worked so hard on, all work has weaknesses, it’s to help you develop a strategy to answer those questions.
These sessions can also be useful to prep the paperwork you’re taking into the viva with you. I had my thesis labelled up with colour coded tabs and had post it notes within it to remind me of key points in case I got flustered (Bayesian modelling haunts me to this day). A practice viva will help you work out whether what you have done works and if you need to change anything before the real thing.
3 – Know your examiners
I’ve already talked a little bit about researching examiners before you select them, but in the run up to the big event there are last minute things that are worth doing. Firstly, check any of their publications that have come out since you submitted your thesis. I had these printed out and annotated to take into my viva so I had prepared for discussion based on their latest work. Second, when your doing your thesis notes think about highlighting your examiners papers that you have referenced and be very aware of how they have linked into your narrative. They will also have published papers adjacent to your work which you may not have referenced, be aware of these and where the conversation topics may therefore drift to in order to help you be prepared.
Third, and this is a bit more work but worth doing if you have time, check out who they referenced. We all have go to references and authors, your examiners are no different. By looking at the reference lists in their papers you can see who their go to authors are and you can see where your over laps are. Also, be prepared for questions if you haven’t cited the same papers. Finally, check the latest publications within the big name journals within your field. Examiners may occasionally ask questions about the latest big work in your field, even if it’s not directly related to your work, to see how well read you are and if you have a wider interest. This isn’t a pass or fail question, but your PhD project may be different to where you end up as a post doc and it helps to gauge how you might make the transition to working in academia more generally.
3 – Think how you want to present yourself
This may seem like a given but it’s really useful to think about how you want to be perceived in the room. How much this matters, in part, is dependent upon some of the research you’ve done. There are some examiners who would immediately think less of you if you turn up in the room and aren’t suited and booted. The main thing In terms of clothing and outfit is that it’s important to be comfortable, whatever route you choose to go down. You may be sitting in that outfit for 6 hours and so you don’t want to have to constantly be adjusting necklines or moving waist bands that are cutting into you. You need to be in the moment and so choose an outfit that helps that by making you feel comfortable in your own skin, preferably professional enough that you don’t risk upsetting anyone. You may find wearing a T-shirt under that top that sums up who you are is helpful or having a mascot in your pocket that you can slip a hand into a pocket and grip if it gets stressful is useful. I genuinely don’t believe there are any hard and fast rules here other than to plan it before hand and make sure you give your an outfit a dress rehearsal to make sure it empowers rather than distracts you.
To be honest appearance isn’t something that is important to me when I examine, being present and polite in the room is waaaaaay more important to me. I find body language is really key in this kind of face to face assessment. You really need to be aware of what your body language is saying. No matter how you feel it’s going it’s important to stay open, smiling and responsive in terms of your body language. If you have a ‘resting bitch face’ it’s worth being aware of it as you don’t want to come over as angry or defensive when you are dealing with the questions. Mostly because you won’t get your point across anywhere near as clearly as it will be distracting for the examiners.
4 – Answer the question they ask not the one you’d prefer
This one is true whether it’s an oral exam or written paper, answer the question you are asked not the one you wish they’d asked. Now as part of your viva prep you will probably learn to answer some of the difficult ones like a politician, where you acknowledge the questions and then deflect to a strength when following up. This is different to just not answering the question. I’m so guilty of this one. I tend to be holding a conversation in my head at the same time as being in the room and so I will proceed to the next question in the conversation I’ve planned rather than listen to nuance of the one I’m actually being asked. I have to really force myself to be calm and really listen to the question. I always make sure I have water or something I can drink in the room and try to force myself to take a sip before I answer a question when I’m feeling stressed or nervous in order to stop me jumping in and make me focus on the question. Hearing the question can be especially tricky in a PhD viva when the questions may be long and multi-component. I took in a pad so that I could write down sections from multi-component questions (just words as prompts) so that I could try to ensure that I was answering everything that was asked of me.
Remember that in a PhD viva you are also able to take the lead in some of the discussion, this is your chance to really talk about your work after all, but it’s important that you bear in mind the point you are trying to make rather than meandering or going down rabbit holes. If you go off topic too much it can give your examiner doubts about your ability to prioritise key points, which can indicate a lack of thorough understanding.
5 – Don’t try to blag it
If you don’t know the answer please just say so, it’s OK. There is nothing worse than having someone try to pretend they know the answer or watching them actively make things up in a viva. Science is about the unknown and there will be numerous points in your working life where you don’t know the answer. If you try to blag it can indicate that you might not acknowledge key failings or points in your work/field you don’t know/understand, not just in your viva but in your practice. This can be a really big red flag and will mean your examiners push harder and dig more to uncover what other weaknesses may be present. It is perfectly fine to acknowledge that you are having a blank and would prefer to come back to a question later, or say that is not something you actually have a concrete answer for but you would consider X, Y, Z in finding an answer. Practice responding to questions you don’t have the answer to, it will stand you in good stead for conference questions and all kinds of other situations in the future.
6 – Give credit where its due
A lot of PhDs and other pieces of work contain sections where you supported rather than led. You may have had some statistics, bioinformatics, or sampling support. I’ve had a couple of (non examination) situations recently where instead of acknowledging this individuals have obfuscated the support they had. If this happens in an exam situation then it’s really concerning, if it comes out in an exam situation and has not been acknowledged in the thesis this is also really not good. It is OK to have work that has been co-created or even led by others, as long as this is well acknowledge and there is enough in your thesis that is unique or led by you. Again, hiding these other contributions makes your examiners question the level of your contribution and they will get the spades out to start digging. Science and medicine is a team sport, don’t be afraid to acknowledge that. Being able to work with others is a strength and not a weakness.
7 – Be prepared to talk about your why
Although PhD viva exams can feel like they are all about the data that’s not actually true. They are also about you as a person, not just the science. It is important therefore to be prepared to answer questions to help the examiners get to know more about you. What was it that made you want to do a PhD? What were your skills and interests when you started? What were your learning outcomes that you were aiming to complete by the time you finished?
A PhD is effectively an apprenticeship in research with the aim that you will become an independent researcher at the end. All that is about more than just data collection. What skills and techniques do you feel like you’ve picked up along the way? What other transferable skills have you learnt? Have you mentored masters students? Presented at conferences? Written papers? Have you undertaken any science communication or public engagement – what have you learnt? Which courses have you undertaken as part of your PhD? What networks have you become part of? What collaborations have you formed? Thinking and preparing to answer questions like this will give your examiners a much greater idea of where you came from and help to bench mark how far you’ve come.
8 – Prepare to talk about the future
The other thing that you should be prepared to talk about (after where you’ve come from) is where you are going to. A common question is ‘if money or resources were no object how would you change the work you have done so far and how would you plan the next steps for your project?’
You will have had plenty of time to reflect on the weaknesses of your work, this is the moment where you get to talk about how you would address those weaknesses by discussing what the next steps for your work could be. Practice both a realistic ‘I would put in a grant to X funding body to continue Y aspect of my work because….’ answer as well as a super ambitious version for if someone took away all of the resource limitations placed upon you.
You should also be prepared to talk about your plans for the future. Are you going to stay in academia? Are you interested in transferring to industry? Would you like to become a clinical academic? This a great way to help examiners understand why you may have made some of the choices of direction you’ve made linked to project, for instance taking a more clinical bent. It is also a good way to have a conversation that may help your thinking about where you want to be in 5 years and if you’re lucky gain advice from some very experienced people on next steps.
9 – Know we’re rooting for you
A lot of people go into the examination room thinking that it will be adversarial setting, the opposite should be true, we are rooting for you. Our job is to support you through the process to get the most out of both you and your work. Everyone understands that you will be nervous, everyone in that room has sat on the other side of the table, has sat in your shoes, they know therefore both how it feels and what it means.
Don’t be afraid to talk about challenges your have faced, in fact you will often be asked to talk about the biggest challenges within your project. It is important to think about what you want to discuss in response to this question: what was the challenge? how did you respond to it? what was the learning you took from it, both about yourself and the work? These questions are important for the examiner not just to understand what your progress to viva has involved but also how you think and respond. This is a great opportunity to talk about things that matter to you and to help the examiners get to know who you are as a scientist. By doing the work to prepare you are doing all you can to help your examiners achieve this. Stay open, stay engaged and stay hopeful.
10 – Keep calm and carry on
Finally, this is a big one. No matter what happens in that room know that it is rarely the end. For good or bad almost everyone comes out of that room with further work, with something more to do. That is very much part of the learning. A lot of people who haven’t done a PhD think that the viva is the end of the process, the big hooray, but I must admit it didn’t feel real to me until I stood at a graduation ceremony in my robes knowing it was truly done.
Whatever happens you will work out of that room with a whole bunch of concrete information that will allow you to put a bow on what will already be (probably) one of the best pieces of writing you will ever do. You will also have learnt more than you could dream in the process of prepping for the viva and during the event itself. You will come out of it as a stronger, better person who will have learnt so much about yourself and what you can really achieve when you put your mind to it.
So as much as any oral exam is terrifying, know that you will actually benefit so much from the process. It’s one of the few moments in your life where people will be forced to listen to you talk about a topic you will know more about than just about anyone in the world. Enjoy the captive audience and if you can try to be in the moment and make the most of the experience.
Today is the Environment Network 2022 event: The Role of Surfaces and Surface Decontamination in Managing healthcare association infection (HCAI) and as @Girlymicro is busy running the show she has tagged in her willing PhD student Sam Watkin, and regular contributor Dr Claire Walker to live blog this event. Let’s get started #EN2022.
What Is the Environment Network?
The Environment Network works to support people in clinical, engineering and scientific roles who are interested in environmental infection control
Do you want to know more about what to do with your water screening and air sampling results? Are you keen to understand the evidence behind equipment cleaning and the role of the environment in healthcare associated infection?
Then welcome to the Environment Network! This is a network for people in clinical/scientific/engineering roles within the NHS and other associated organisations who are interested in the role of environmental infection prevention and control in preventing infection.
The aim of the network is to support infection prevention and control professionals involved in commissioning, environmental audit, water, air and surface testing within their Trusts. By working together we can share best practice between Trusts; as well as circulating the latest evidence and discussing personal experiences.
We are so excited to be live blogging the wonderful EN conference this year. Dr Elaine Cloutman-Green BEM opens the conference setting the scene for a wonderful day of networking, learning and discussions with our clinical, industry and academic colleagues. We’ve all come here today create a friendly network of experts. Because sometimes we all need to phone a friend at 4.30 on a Friday when everything is going wrong, and this is the perfect opportunity to grab every experts number.
Morning Presentation Session
The esteemed Professor Jean-Yves Maillard from Cardiff University leads us through his thoughts on options for surface clean and surface decontamination. This topic is very much at the forefront of our minds in the EN, and whilst there has been huge progress in hand hygiene (thanks COVID!), Prof Maillard’s fascinating talk demonstrates how many factors have to be considered to really make a surface ‘safe’. There are so many variables to consider; what product to use, how effective a product is, what factors impact on that efficacy and unique multifaceted challenges we face in this field particularly when it comes to training and developing best practice across healthcare specialisms.
He raised a very interesting and important point when thinking abut surface decontamination – how do you define a “safe” surface? Let’s talk about norovirus – when we consider that it takes 10 virus particles make you sick and there are one billion virus particles per gram of vomit or faeces – you best hope your cleaning strategy works or the whole cruise ship (or worse hospital ward) is going down. The difference between looking clean and being safe is shown, just because it looks shiny doesn’t mean that you can eat your dinner off it!
As we come to discussing decontamination chemicals, the focus turns to compliance with surface decontamination protocols which are essential in maintaining environmental decontamination efficacy. Prof Maillard raised fascinating points on how products are used and why this matters. Different delivery methods, such as spray, foam or pre-wetted wipes, have significant impacts on the efficacy of compounds and their proper use is often hard to consistently achieve.
Further complicating the issue, different microbes have different susceptibilities to different decontamination agents. Wipes that can remove a Gram-negative pathogen can do very little against a Gram-positive. We know that some key pathogenic organisms like Clostridioides difficile require higher levels of disinfection compared to others, but other pathogens often have different requirements to each other. Multidrug resistant organisms can often be resistant to quaternary ammonium compounds meaning you may be able to clean off antibiotic-sensitive Klebsiella, but the drug-resistant ones could remain. Similarly, despite some company claims to the contrary alcohol gel does nothing against C.difficile spores.
Prof Maillard detailed just how important this is by describing some shocking cases of where cleaning has gone wrong. The use of inappropriate compound concentrations and a lack of consistent training on new products can have truly terrifying consequences in the hospital environment. In untrained hands, cleaning can actually make the situation worse not better, for example poor cleaning with can spread viruses around a patients room rather than remove them. We all have so much to learn from not taking detail for granted and how basic precautions like ‘one wipe, one direction, bin it‘ can prevent healthcare associated infections.
As the talk comes to a close we ask can we trust claims of residual activity of decontamination products? Does it really leave a surface ‘clean’ and ‘safe’ for 48 hours? Do these products really work as well as companies or their representatives claim? Prof Maillard says we really can’t trust everything we read. A disinfectant used improperly can select for microorganisms resistant to that product. This highlights not only the importance of choosing the right disinfectant compound, but on using it correctly too. With pandemics in the press, it’s more important than ever that we have an open dialog and solid evidence base for what we use, how we use it and when to use it to create safe environments for both patients and staff.
In our second presentation of the day Karren Staniforth from UKHSA explains the role of novel decontamination techniques in healthcare
It’s important to acknowledge that in decontamination, one box does not fit all. A high risk patient post chemotherapy has very different requirements to a healthy adult popping to the GP to ask for a repeat prescription. Furthermore, we know can’t sterilize everything. It simply doesn’t work that way, so we need to be decontaminating to an appropriate level for the site. If we can avoid high-level sterilization we should as they are expensive, potentially damaging to the site and generally involve harmful chemicals. So how do we manage surfaces categorized as ‘low risk’? For those of us who aren’t so familiar with disinfection in the low risk setting this means something that comes into contact with intact skin. A huge number of different products are available but today Karren is are talking about UV light, and gases and vapours – why we might want to use them and how we might automate these systems.
Karren raises an important issue that automated decontamination techniques don’t remove human error, particularly as they generally require humans to set them up. We still need manual cleaning of rooms when using these, so they very much are there to support environmental cleaning and decontamination, not to replace manual decontamination. However, there are some incredible advantages to an automated system – not least that they are highly reproducible thus much easier to audit and, with proper calibration, should be highly precise and accurate.
Karren tells us why it is so important to use and understand what disinfectant efficacy really tells us, and why it is crucial to be sceptical and to question the manufacturers claims about their products. She details a fascinating history of working in infection prevention and control, and the journey from cleaned rooms actually causing MORE infections to introducing novel technologies and strategies that are proven efficacious. Her talk is peppered with wonderful real world experience of infection, prevention and control. Simple strategies like removal of felt notice boards from wards also had a huge impact in improving cleaning strategies to rid geriatric wards of C.difficile. As a member of the EN steering group (Claire), I am heartened to hear how sharing our stories can improve real world patient care.
Karren closes her talk with some fascinating points about cleaning frequency rather than specificity. We really need to thing about exactly what we are trying to achieve in each setting, and often a bespoke mixed-approach will be what fits the bill.
Post Coffee Talk Session
Claire has been let loose on her own now – with Sam giving his presentation next.
Revived by our coffee we move onto the much anticipated talk by our pal Sam who, with the knowledgeable Helen Rickard, is guiding us through monitoring microbial surface loads – how we should approach it in healthcare and some key findings from their exciting work. Monitoring let us pick up presence and movement of clinically relevant microorganisms in the hospital setting promoting surveillance and targeted treatment programs. This is done routinely in hospitals, but can be stepped up after an outbreak or when transmission is unexpected.
Sam gives us a step by step guide to the different samples and how you might process them to identify the microbial population present. His data demonstrate how important continual sampling is – just counts of microbial species are a snap shot of the situation, and when repeated sampling is done microbial persistence is revealed telling the whole story.
Helen Rickard walks us through why sink surfaces are so important in HCAI. Sinks are the perfect environment for microbes to thrive, and the presence of running water disperses and aerosolises bacteria. They are also often very close to patients. Helen is interested in the impact the patients will have on sink surfaces. Her exciting preliminary data reveals that numbers of organisms detected on sinks double when patients inhabit wards, and numbers of human commensals massively increase. We’re already excited for Helen to come back and tell us more when she is further along into her project.
Dr Marco-Felipe King from the University of Leeds is up next, telling us all about how one can model the impact of surface decontamination. Dr King’s work links airborne and surface contamination, looking at the impact of ventilation on surface contamination, and then transmission onto human fingers. We watch an incredible computer generated model depicting how viruses spread across a ward onto surfaces challenging the myth that viral particles don’t deposit on surfaces. Dr King’s enthusiasm for understanding microbial recontamination of surfaces (why microbial loads sometime increase after cleaning) is infectious. He showed several delightfully complicated formula to model these (and explained them very well!). In Dr King’s own words, “something funny is going on” with the data, which inspired lively discussion amongst all the delegates. He showed how much relative humidity matters for transferring organisms to hands when surfaces are touched – basically proving you should never lick your fingers when on the tube.
Dr Lena Ciric from University College London brings our morning session to a close with a fascinating talk all about the importance of surface loads, and how they differ in healthcare and the community.
Dr Ciric kicked her talk off by discussing the challenges of achieving low surface loadings in the healthcare setting, explaining that while we want microbially clean surfaces in hospital, we have evolved to live with microbes. She highlighted how few guidelines actually exist for surface loading levels, and the challenge this presents to standardisation. Dr Ciric’s data looked at colony forming units collected from a range of locations – hospital wards, the FA cup final, the Brits and even the Tube – to understand what a safe level of microorganisms on surfaces should be. Safe to say we are never touching a surface on the tube again. But it’s not simply a case of how much of something is there, we need to understand what microbial species are present. Her data on presence of SARS-CoV-2 presence showed that colony forming units (CFU) didn’t reflect how much SARS CoV-2 RNA was present on the tube, so whilst the CFU guidelines are interesting more work needs to be done. Really highlighting the importance of, in Dr Ciric’s own worlds, ‘you’ll find what you go looking for’!
Reflections on Surfaces
What an absolutely brilliant, informative and lively morning. It’s difficult to condense such a varied and thoughtful set of presentations into a few take home messages.
The importance of moving past the marketing – we really need to question how good products are, validate them for use and develop sound guidelines.
Human factors are hugely important – without proper training even the best tools are not helpful
The overall takeaway for the transfer of organisms to people’s hands: “it depends”
TLDR: @girlymicro let Claire and Sam loose on her blog, who had lots of fun but she should definitely have provided a word count.
I thought I should start with an apology, this one is all about me. There is a point to it but you may have to get through a chunk of stuff about me first. If you don’t fancy that there are links to some of my other posts at the bottom that you may fancy more.
Everyone tells you that academic qualifications aren’t everything and they really are not, depending on the path you want to take. In many ways the more qualifications I have the more I question their validity, but I get to do that now from a position of privilege where I no longer really have any skin in that particular game. That said A-level and GCSE results have come out in recent weeks and it got me remembering the day I received mine, more than that it made me think about every time I stood there waiting for a sheet of paper to be put up on a wall or to open an envelope (yes I am that old 😉).
If you look at my CV now you’d see a pretty good list of academic achievements but there are things that you don’t see. Past a certain point no one lists their GCSE or A-level grades. You also don’t see the fact that I have never been the smartest person in the room, I’ve never been the top. The reason you don’t see it is because none of that actually matters, it’s about the body of work rather than a single point in time. When you get those results however no one tells you that or even if they did you probably wouldn’t believe them. Those results are your whole future, they feel like your whole world. I wanted to just write something to put out there that shows that no matter what you received it doesn’t have to define either who you are or your future, it’s just one step on the way.
GCSE horror show
Frankly my GCSE years were a bit of a horror show. Not because I didn’t want to study or engage but health wise it was basically a disaster. I caught glandular fever (Epstein Barr virus) and ended up with such bad swollen lymph glands under my arms I couldn’t lower them for days at a time and turned yellow due to the hepatitis. On top of this I slept 23 hours a day and it just didn’t get better. I ended up with post viral fatigue and for my 5th year at school managed an hour a day, on a good day. I was withdrawn from all but the basics (maths, english and double science) and told I should plan for failure.
I sat no mocks and frankly had no idea what day it was let alone feeling on top of anything. School became a terrifying place where I could see everyone else moving on rather than a place where I fit in, as I had loved to study. I never really had a lot of school friends but all but one basically forgot I existed (cheers to Heather who always stood by my side). I missed all the big occasions, no last day of school with signatures for me, no last school disco. I was just left behind and I really started to believe the tale that I was being told that my aspirations were over.
Things got worse when I sat the exams. I managed a weekend of revision pre the written papers, although it really blew me out. I did that awful thing of not really reading the instructions as I was so nervous. My english literature exam was up first and instead of answering 2 of 5 essays, I answered them all. I couldn’t understand why I was furiously writing whilst everyone else looked so calm or had finished with loads of time. It just fed into my panic. With 5 minutes to go I finally finished and went back to the start to see the words 2/5 glaring at me from the front page. I felt like I’d screwed it on day 1.
Come results day I just didn’t even want to go. I was so convinced of my failure and that I had sealed my fate. I had no plans for next steps, I had no college or A-level plans. I picked up my envelope and I suspect other people’s tears were for very different reasons. My 2 A’s (english lit and language) BB (duel science) and C in maths were so far from what I had hoped for at the start but were so unexpected on the day. Everyone stood around me with 11 and 12 passes but my 5 meant that I was still in the running. I still had a chance. I went back home and went to bed for a week, there was no energy for celebrations and dreamt of what next.
A-level winging it
As I said I’d made no plans for A-levels as no one thought they were an option. My mum (who is loyal, devoted, loving and probably a genius) swung into action in a way that I will be forever grateful for and don’t deserve. She got me a last minute place organised to do A-levels at the secondary school less than 5 minutes from my home. My original school were so focused on grades and success that it wasn’t even discussed as an option. So 3 weeks later I’m due to start at mixed sixth form, having only studied in a single sex environment since 11, with no one I knew, having never even visited the school. Nervous was not the word. The school knew about my health issues and to be honest the word university was not being mentioned. So that I could manage health wise I started A-level biology, which happened in normal school hours, and A-level drama that had some evening classes so I could rest during the day. That was it. 2 A-levels. Only 1 of which was considered serious. I set to it.
In what will become a theme for my life I felt so far behind. For my GCSE exams I studied the minimum possible to be able to pass for a weekend, that did not enable me to keep up with my peers during A-level biology classes. I was the idiot who knew nothing, understood nothing. If I had had friends I probably would have understood earlier that most of my class mates felt the same way but I didn’t, the switch from GCSEs to A-levels is hard but I thought it was just me.
Drama on the otherhand was a revelation. For someone who was struggling to find a refreshed version of her identity and new place in the world as the plan she’d had was falling by the wayside, drama was my safe space. You could choose to be loud or quiet. You could often choose to watch or engage. I was in a place where my choices were given life. Not just that but I didn’t feel behind, the texts were new to everyone, it was a very different space. I still didn’t fit, on the first day they thought I was their teacher not a student, but being able to academically engage in a place I didn’t feel like a failure was something that gave me hope, it kept me going. It’s partly why I’m still so passionate about the use of STEAM now. When I had no other way of being me it helped me find myself.
By the end of my 1st year of A-levels I was beginning to feel a bit more like me, a bit more able to think about the future. I still wasn’t physically right but my mind was a bit more back on track and I wanted to be able to plan again. I knew that if I wanted to even apply for uni that I would need 3 A-levels plus general studies and I only had 2. Let’s put to one side that I had no idea what I would apply to study I just knew that 3 A-levels was the first step. As I’ve said the school where I was doing my A-levels did evening classes that were open to everyone. I can’t even remember how it happened but I found an amazing psychology teacher who I spent some time talking to and who said she would help me. We came up with a plan. There was no way I could cover 2 years of psychology in 1 but I didn’t need to. The course was split into core and optional modules. If I took some of the evening classes and some of the day classes across years I could still cover all the core components. I then just had to cover 1 optional and make sure that I knew it super well as I’d have no essay options – I’d have to be able to answer the one that came up. I also registered on general studies knowing I would just have to turn up to the exam and hope as I wouldn’t be able to physically manage any more classes.
I also knew that despite ‘the plan’ I wasn’t going to be well enough to manage full time uni the next year and so I would give it everything I had and then defer my place for a year.
I basically spent that year working and sleeping. I didn’t have much left in the tank for anything else, but I had a plan. I also had an amazing cheer leader in my mum who repeatedly let me know that her love was unconditional and that she had my back, but I could also stop at any point if I wanted to. The choice was my mine. That word choice is so important when you feel like your options are taken from you. I chose to go for it. At the end of that year I got my envelop. The uni’s I’d applied to required ABB or 3 BBB with the A or B in biology. I got 2 As a B and a C. The C was in biology. The A’s were in psychology and drama. I didn’t get in. I can sit here and say that the fact that I managed to get passing grades was amazing, that to come from nothing to a C in biology was such an achievement, but none of that is true. I felt crushed. I felt that the people who told me I couldn’t make it were right and what was I thinking. Then someone stuck me a room and handed me a phone and told me to call clearing. I had no idea what clearing was or what I even want to study, but somehow an hour later I’m going to a city I’ve never even visited (Liverpool) to study a course (general science) which I didn’t even know anything about – apart from the fact that it would enable me to choose my science speciality later on which at that moment felt sooooooooo important.
Everyone moved past me once again as I deferred for a year and focussed on getting well. I also took a part time job, not only to help me earn some money for uni (we weren’t rich and I’d need it) but also so I could see how I managed to see if I was OK to go.
University catch up
I turned up for my first week at uni and if A-levels had been a shock they were nothing on this. EVERYONE and I mean EVERYONE seemed to be more prepared, understood more and frankly knew more than I did. I had been so relieved to just arrive I hadn’t planned for what would happen next. As it turned out 3 main things occurred:
One – I learnt the importance of finding my tribe
Two – I learnt to hide my fear and insecurities
Three – I found ways around things so that I could hide my knowledge gaps
Now, some of these I’ve written about separately on this blog, like finding your tribe, and as a life lesson it has stood me in so much good. I found a small group of people who I could learn with, who didn’t make me feel foolish and behind, even if I didn’t ever really share with them how I felt. One person in particular, Diane, became my study buddy and we would have late night chinese, work out pass margin requirements and all in all keep each other going. She was a bridesmaid at my wedding and I was maid of honour at hers, if it wasn’t for Diane I wouldn’t have made it through. She’s northern, straight forward and stopped me listening to the voices of doubt and fear that troubled me in the middle of the night.
As for the other two things I learnt they have their pros and cons. I’ve reached a point in my life now where I’m pretty open about my fears and insecurities, I write this blog after all. The thing is fear festers because we don’t talk about it and one of my motivations in writing this blog is so that others don’t feel alone in their self doubt and their challenges. I can do that now though as someone who has worked through a lot of them and who has (thankfully) gotten to a place in her life where I’m less bothered by what people think of me than I am in trying to help others find their way. That certainly wasn’t the case when I was a 19 year old who was still struggling to feel like she belonged. This is an after uni story, but I still remember my first week as a trainee Clinical Scientist and having people stare at me as I tried to pipette into an agarose gel, and having people comment on whether I was back pipetting and how interesting my style was. I had no style. No one had ever taught me how to pipette, I had never run a molecular test, I was a Zoologist who ended up in microbiology after all. I therefore had to learn, especially in the competitive environment I was in at uni, where the bottom 50% got booted every year, and as a trainee to cover and not let my lack of skills be seen for fear of what that might mean for me.
I spent my entire time at uni volunteering to do the drawing or take other roles because no one had ever shown me how to focus a microscope and I was terrified that I would be found out. This haunted me enough that when I sat FRCPath I actually had close friends run trials for me on different types because even the memory of it gives me panic attacks to this day. No one ever showed me how to do dissection and so again for my first 2 years at uni I covered and did the best I could. It was assumed that everyone had gone to schools that had access to equipment, that had run these types of classes and then to add onto to that my lack of experience due to illness, it all just meant I felt at sea. In my third year I faced an eight hour dissection exam and I knew it was going to be a disaster. After three years of uni though I had finally found a lecturer I trusted and a couple of friends who I felt would stand by me, and so we approached as a collective and asked to be allowed to have specimens and practice on weekends. Me and my dogfish George got an A in that exam and I cried in a way that is only rivalled by passing FRCPath. It took me three years to have enough trust in other people and myself to ask for help, not because I was afraid to do the work, but because I was afraid of what it would mean if they rejected my request.
So what does all of this mean and why have I written it. Firstly, I’ve written it because I want anyone out there to know that if things didn’t go well for you there are still pathways ahead. We may not take the most straight forward path but we end up in similar places and sometimes the learning that will give us will be invaluable for the rest of our lives.
Secondly, I want those of us who are now acting as educators, leaders and supervisors to bear in mind that not everyone is joining you at the same point. There will be smart people out there who are turning up at day one who will not necessarily have had access to the resources or opportunities you think they have. Making assumptions that everyone is started from the same place sometimes puts people back even further. This is especially pertinent as we have trainees about to start with us. Taking the time to have a non judgement based conversation about prior experience can make all the difference to those who feel lost in our world where we take so much for granted.
Believe it or not there are so many things I’ve learnt about myself that I see the way I got here as a strength and not a weakness. I’ve never been the one at the head of the class, and the route that I’ve taken, although circuitous, now pays real dividends as I understand so much more than if I’d taken the direct route. It’s also taught me valuable lessons about myself, what I value and what I can achieve if I can get over my fears of how people see me. I’m used to hearing no, I’m used to hearing that’s not how it’s done and that it won’t work for someone like me. All of those things felt horrible but now I’m so thankful. Those no’s have taught me to be strong and to break down barriers. Those no’s have in the end enabled me to truly be the person I wanted to become.
Finally, and I can’t say this enough, find the person who sees your value even when you can’t. Find the people like my mum, my husband, like Heather and Diane. Find them and even when you haven’t got the strength to articulate what you are truly afraid of they will still be the people who stand by your side and guide you. Find your tribe and you will never truly be alone again.
It feels like the time of year when people start new things in their lives, new jobs, new courses, new career paths. So many people I’ve been speaking to lately are moving onto bigger and better things, with many of them starting their journeys as senior leaders both within academia and the NHS. I’ve spent some time talking to them about what I found might be different and some of the challenges about stepping up into a leadership role. Now, my journey to consultant and Lead Healthcare Scientist was not particularly linear so I may have some thoughts about this that aren’t universal, but after doing some thinking the below are what I’ve come up with in terms of how I think senior leadership roles are different and how my thinking has changed whilst in post.
It’s no longer all about you
First and foremost this is the most important thing that I feel is at the heart of what I try to make my leadership decisions based on. I’m now out there representing more than myself, I’m representing a team or even a whole workforce and sometimes therefore my wants and needs will have to take a back seat. I’ve been in meetings where I have given up something I want because actually it enabled something to happen for the wider good of my workforce. I personally don’t think there’s a place for selfishness once you are in a band 8 + position, although I’m also sure that I’m not perfect and probably don’t always make the best calls, it just means I make a conscious effort to keep it in mind. That doesn’t mean that sometimes things don’t work out so you get the best of both worlds, but when you are representing more than yourself you have to do exactly that, represent.
It’s no longer all about doing
One of the things that I think can be especially challenging when stepping up into a senior role, when you are more used to an operational or service provision role, is making the switch from being the person who does to being the person who sees. What I mean by that is that a lot if my job is about constantly having one eye to the future. Where are we going next? What are our current strengths and weaknesses and how do we manage them moving forward? What are the challenges coming down the road and what can we do now to prepare as much as possible? Not only that but once I have a path in mind I have to develop how we are going to get there and communicate that vision as broadly as possible. Obviously this isn’t done in isolation, it needs to always be an inclusive process, but a lot of the thinking sits with me. If you continue to only have an operational view, it can rabbit hole you into the present, it can then be a struggle to emerge for long enough to do that vision piece. So, although it may be comforting to get back to the bed side or to the bench, you have to make sure you’re doing it to maintain skills when needed rather than avoiding seeing the landscape laid out in front of you.
It’s no longer about picking and choosing who you work with
We all have people we love working with and some people where, because we don’t necessarily share the same vision, it is more challenging. As you become more senior you have less and less choice about who you work/collaborate with, those decisions are made due to the work and not due to personal preferences. This may sound odd but I genuinely believe that this is not only right but a good thing. If you only work with people who are easy, who see the world the same way you do, are you really working to reflect the wider attitudes of your staff? Although not easy some of the best project outcomes I’ve had have come from working with people who have very different attitudes, values and objectives. If done well and professionally these relationships enable you to have constructive challenge and see work or scenarios in a way you never would alone. They may not lead you to change your direction but they will always help your thinking as to why, and often help you to develop and articulate your arguments in a way you may have not gotten to on your own. Best case, you’ll get an outcome you couldn’t have achieved on your own, worst case you’ll have clarified your thinking. This doesn’t mean that I don’t (as someone who likes to be liked) find this a particularly challenging aspect of leadership, it’s just that I also really see the value in it. Hiding is no longer an option.
All those people you thought were on top of it probably weren’t
If you are like me you probably spent a lot of time in previous roles being amazed at how productive your seniors were and at how much they achieved. Now I’m probably biased here, but rather than judge myself harshly I’m going to extrapolate instead that all those people I looked up to just covered up their failures better than I do. My experience of stepping up to leadership is that you will have more work than you can manage at any one time, you will never clear the decks and you probably won’t ever ‘finish’ anything. That’s because you will move from a task based role to one that is much more far reaching and often conceptual. Some days I really miss just being able to spend a Friday doing 16S rDNA sequencing, unless I screwed it up I knew that at the end of the day I knew that I would have achieved something and that I would then action a patient result. Now most of my days are moving things forward by inches, or if I get to the point where I get a task off my list it is so rapidly replaced by something else I barely notice it, let alone have satisfaction as a result. This isn’t to bemoan this way of working, it’s just different and if you come from a very task orientated role it can be a little demoralising at the start as it can be hard to see progress. It’s really worth therefore finding other ways to track your progress so that you can still find a way to visualise it. I sometimes try an annual wish list for instance where I check in over a period of months rather than days to see how things are coming together.
You will spend more time than you thought possible on emails and calls
It’s currently 6pm and I’m just trying to get some words down here before I leave work. I have spent since 8am this morning trying to recover from the email backlog from 3 days off work last week, I’m proudly down to 283 which need actioning. Email is the quicksand of my working life, when combined with days that often have meetings back to back from 8 – 6, they are almost impossible to keep on top of. The main thing I’ve tried to develop are some tools to try to ensure that I don’t miss anything devastating and urgent. That said if it is devastating and urgent you should probably be calling rather than sending me an email. I’m quite up front with people. If your email comes in whilst I happen to have a window and I’m staring at an inbox you will probably get a response within 5 minutes, if not it could be 5 months. If you need a response send it at least 3 times, preferably with a red flag and then at least it will get to the top of my to do list. At the height of SARS CoV2 I was getting upwards of 600 emails a day, thank god that’s reduced, I just couldn’t keep up. Over time I’ve also tried some strategies to protect my diary where I can. My fab IPC team suggested a 1.5 hold in my diary every day for urgent meetings so that they should (almost) always have a slot which they know is theirs to put it meetings when needed. I also try to go to less meetings that are just for information and not for action, otherwise to be honest I would never manage to eat or go to the bathroom. Feeling out of control is therefore pretty normal and it’s about strategising so you keep on top of the key things. You will also develop language that will help you cope and politely deflect some of the things that could be handled by someone else. I used to feel bad about delegating, but actually a lot of the time it offers development and learning opportunities for others. If done appropriately it will not only buy you a little breathing space but it will enable others to continue their own career journeys.
Sometimes it’s your job to be the shield
One of the things that comes with being the one to develop the vision is that you also (often) are the one that can see the storm approaching. This one for me goes hand in hand about the role no longer being all about you. Sometimes it’s my job to stand in the front and take the hit, sometimes that’s being shouted at by a family for the tough call, sometimes it’s dealing with the response of other senior leaders. This is why it is sometimes lonely being in a senior role and you will need support for you as an individual. Senior roles are often not that linked up and so you won’t necessarily have someone who is doing the same post as you, you will therefore need to be pro active in building your own support networks. These will also help with the visioning piece as the more connected you are the more pieces of the jigsaw you will see. The more you understand the drivers of what is going on in any particular situation the more you will be able to respond with understanding, and the greater the chance of improving a situation rather than making it worse. There is no getting away from the fact however that sometimes you just have to don your big person pants, stand your ground and deal with whatever has come your way with as much integrity and grace as you can muster.
There are weights you don’t see
I recently took hubby away for his big birthday to Disneyland Paris. Towards the end of the holiday I looked at him and I suddenly realised how different I felt. For 6 days I had not been Dr Cloutman-Green, I’d just been Dream. I’d made no decision bigger than what I wanted to eat/drink or what ride I wanted to go on next. I felt stones lighter and so much freer. I hadn’t realised the weights I’d been carrying with me. I don’t know how much of this is COVID but I find there is an unseen, and some days unbearable, weight that I carry with me and that I don’t even realise it’s there until I put it down for a while and take off my healthcare hat. This may just be a me thing, it may be a pandemic thing, but if you get afflicted you have to make sure you that you put the weights down from time to time and do whatever it takes to make you feel free again, for me it was going to a mad hatters tea party!
You will always be more than your job, you will have other roles (mother, wife, carer, sister, father, son, brother etc) and we can’t always sacrifice these for a job that can become all encompassing if we let it. In the long term it will make us poorer both at the job and as human beings. Some of these weights we will put upon ourselves and so need to work on ourselves to resolve. You will not have all the answers on day one in your new role, you are constantly going to learn and develop, in fact I hate to break it to you but you will never have all of the answers. You will fail at things more than you’d like. This is part of life, it’s part of leadership and it’s part of learning. It’s OK. The sooner you come to terms with that the sooner you can remove an unnecessary thing that might weigh you down.
I for one didn’t realise any of the above, in fact I didn’t even really realise I was a senior leader, it kind of just snuck up on me. I think the capacity to influence and lead change is worth so much more than the challenges that come with it. For me as a Trust Lead Healthcare Scientist I get the immense privilege of seeing so many people develop and flourish, who will hopefully one day give me a job, I wouldn’t change it for the world. If you have just stepped into a senior post or are thinking about it I hope the above helps and makes your realise you are not alone in the challenges you face and that overcoming them makes us better, even if the path is sometimes bumpy. For those of you not yet at that point I give you the advice that I wish someone had given me, enjoy the freedom, enjoy focussing on you and your career pathway, enjoy making choices that are your own and don’t be in too much of a rush to get to the top of the mountain.
I posted last week about some of the reasons that I think social media can be powerful and positive. This week though I want to talk a little bit about the other side of the coin, the fact that social media can end up being a source of enormous pressure to the detriment of both our wellbeing and our career choices.
I’m a great advocate of the use of social media as scientists, I’ve even given the odd talk about it. That doesn’t make me naïve to its risks. We tend to talk about platforms as if they are formed of a cohesive community with the same rules of etiquette and values, but they aren’t. The reasons that people use social media are as variable as the number of people who have accounts. Therefore if you fall into the assumption that the posts you are reading are made using the same motivations and ethics as yours, you can end up in a position where posts and responses to them can cause upset, self recrimination or harm. So what review and thought processes do I try to undertake when I post and engage with posts by others, either emotionally or by responding?
Am I comparing like with like?
I’ve had conversations with a couple of my PhD students over the last month or so about the dangers of benchmarking against people who you don’t really know. You don’t know what their project is, you don’t know what their education and learning objectives are in comparison to yours, you don’t even know if their description of where they are at reflects the reality of what is being shared.
Even for me I can sometimes see posts on social media and when I’m having a bad day can fall into a spiral of asking myself ‘am I good enough?’ ‘do I work hard enough?” ‘do I know enough?’ ‘am I successful enough?’. The thing is that, especially on social media, posts are a projection of self but an edited one. The same thing happens when you have PhD get togethers down the pub but the reach is different and you have at least a better chance to evaluate what’s being said.
It’s easy to fall into comparison but you have to know what your comparing against. For PhDs and training programmes especially, you’ll have your own mile stones and training goals that will be personalised to you and your learning needs. It is folly therefore to compare yourself against someone else as their goals will be different. Discussing shared barriers and approaches can be helpful however but the race to compete about papers, data and presentations rarely is.
Are they only sharing the good stuff?
I personally am really wary of accounts that only share their successes. I know I go on about this a lot, but the most learning often occurs in the failures and if you’re not prepared to share the learning I’m less willing to engage with the success. Nothing is brilliant all the time, no job, no project, and so if an account only shares the hype I am less likely to use it as a benchmark. I’m also less likely to share it with the community, as I worry about the impact that amplifying those voices might have.
In a similar vein, accounts which are not about conversations and supporting the community appeal to me less. If you have an account that is only there to disseminate your success, your papers etc and you don’t also work to amplify others I am less willing to engage. To me, social media is about the opportunity to converse with a diverse group of people. Some accounts are the equivalent of standing on top of a hill with a megaphone and so I take that ethos into account when reading their posts.
Harder, faster, stronger
I see a lot of posts these days talking about how many extra hours someone works, about how many work hats they wear etc. There’s a strong push for this on some academic accounts where people make comments that if you aren’t prepared to work every weekend you can’t be an academic. I also see it more and more coming from some Healthcare Scientists and I’m not sure it’s a healthy trend. There are always times when we have to go the extra mile but wearing it as a badge of honour concerns me. I’m also aware that some of this doesn’t actually reflect the reality, it’s almost like it is what is now expected.
I’m sure that I am guilty of this one, but I hope that most people read my ‘I’m working this weekend’ as ‘my god I’m working again this weekend’. If not you have my apologies. Step up when you have to but also find the strength to have boundaries as it will make you better at all you do.
One last thing on this while I have my rant on. Discussing the ability to do long hours is a privilege, there are many people for whom is this not possible. Parents and carers are excluded from progression if this is what is required. I work hard but I physically suffer badly for it. I don’t want to have my face and hands swell for the rest of my career. I want 8 hours sleep and weekends off if its not an emergency. My mind may be willing but my body is most definitely not. So lets not imply that the only way to be successful is to get 4 hours of sleep a night and to become the job, we all owe ourselves and our families more than that. Rant over!
Whose is the driving seat?
I’m thinking I’m not alone in this one. There are times when I read something and it will send me into a proper shame spiral. Sometimes it’s something as simple as seeing a micro question and not getting the answer right, sometimes it’s seeing an opportunity that I feel like I should engage with and don’t have the energy to and sometimes quite frankly it’s seeing things like a meeting day on my specialist subject that I didn’t know about and makes me question my knowledge/impact. The thing is very few of these reactions are real. They are driven by my anxiety and 9/10 time I will have read exactly the same tweet and not raised an eyebrow. So if it’s about me and not about them what do I do?
Well to be honest I turn off Twitter, step away and have a cup of tea and check my thinking. What is it that has triggered me? Why has it led to that response? In short I make sure that I get back in the driving seat rather than being a passenger to my responses. It’s like those emails you get that you know you shouldn’t respond to right away – I always do and I always regret it, I have impulse control issues. At least on twitter if I step away immediately and don’t engage then I can do the self reflection to try to ensure I’m the best version of myself when I do. We’re all human, we all have moments of jealousy or self doubt, it’s how we respond to those moments that define us. This may be especially true on social media where your responses are out there for the world to see.
Is it helpful? Is it kind?
I definitely share my successes and challenges via both this blog and across social media. My aim in doing so is not to dwell in either but in the hope that sharing will help others, in seeing the opportunities available to them or on feeling less alone. I do have a constant conversation with myself about whether the level at which I share content from myself and other is correct. I know I’m never going to please everyone but I try to at least be honest with myself about my intent when sharing. I saw the tweet below a few weeks ago and it really enforced for me the need to continue with this evaluation. It can never be a response of ‘well I managed it so why haven’t you’. So much of social media strips away nuance and 280 characters will never tell the full story, and so we need to be clever about telling as much of the truth as we can. When people respond in a way that signals that we haven’t managed this it’s important to bear in mind not just what we believe we put out there but also what the reader received when they saw it. I’ve often found the 2 are not the same as they will be looking at it through a different lens to us. Sometimes just acknowledging this is what is needed to make the other person feel heard. I think this is worth remembering as both the maker and receiver of content.
Is seeing believing?
I am super guilty of this one. I’m nothing particularly special and so I fall into the trap of believing that because I did it anyone can do it. I think in terms of intellectual ability this is true as I’m no smarter than anyone else, but I also have a super supportive husband, no kids and research funding. Those things open doors and enable me to have the time to focus on things I want to achieve, whilst feeling supported to do so. This is not the case for everyone and so everyone’s scenario is different.
When you look every year on the day that FRCPath results come out, you see way more people posting that they have passed than those who post they have failed. People hardly ever post to say they failed their PhD viva’s or have come out with an MRes instead. It is worth therefore being wary of using the evidence before your eyes in terms of evaluating how many people actually succeed. I think when I took FRCPath the pass rate was about 40% and for my NIHR Fellowships it has been even less some years, not the 80 – 90% you’d extrapolate from what you see. Making career choices on the basis of this is pretty dangerous. It sounds easy therefore to say you should meet up and speak to people to understand what the reality is. That is sometimes easier than it sounds, not everyone will know someone who has been interviewed for an NIHR Fellowship for instance. We don’t want to limit ourselves and others by saying if you don’t have the connections you can’t strive for the opportunity. What we do need to do is make it easier to see the reality of those options and also make ourselves available for the conversation about what it felt like to attempt it. If we are going to celebrate our successes publicly we should also try to be generous with our time in order to make the same opportunities more widely accessible, with all the context specific information that entails.
You don’t have to take on board all that you hear
That said we’re scientists and healthcare professionals and should be able to look at information available and critically evaluate it. It is easy to get bogged down and not to be able to see the woods for the trees, you’ll get offered so many different opinions and perspectives that it can sometimes be hard to work out whose voice to listen to. Not all of those voices should however have equal value, some you will know more context specific information about than others. When I’m in doubt, when I start to spiral, or when people are critical I tell myself the advice below and then re-evaluate what I’m hearing in light of my relationship and the content of the advice received.
Finally, the other things are more about my own expectation setting. I try to remember why I set up my twitter account and what I was trying to achieve with it. My account is mainly professional, although I also like to share who I am a person, as I think that’s important. It is not my personal account which I maintain on Facebook for checking in on my family and use an occasional safe space to vent. If my Facebook friends have science questions I direct them to Dr Cloutman-Green on twitter because I like to have a safe space elsewhere where I’m not Dr or being reviewed or critiqued. I go back to this when I struggle with dealing with managing my posts or feeling low. I remember the lens through which I am supposed to be viewing the information. I also know that when I’m tired and in a place where my inner critic is running wild, that it is not the time to engage and to take a break, get some sleep and come back when I feel more like myself.
Social media, like most things in life, can be a double edged sword. It has the power to connect and inspire, it also has the potential to isolate and feed our inner demons. Like any adventure it’s therefore worth being prepared and ensuring that you know why you set out and what you want to get out of it. In times of stress know when to walk away and at the end of the day, know that you have friends who can act as a more rounded sounding board if they are not limited to 280 characters, they may even have gin.
I’ve talked previously about benchmarking and the pros and cons of trying to work out if you are doing OK by comparing yourself to others. As scientists we have a tendancy to look for evidence, in the form of numbers, to enable us to do this. In terms of research measures the main ones that I have heard of being used are the h-index (Hirsch index) and the i10-index. These numbers are not just used by us as individuals as marker of impact and progress but they are also used by promotion panels at universities and by external reviews as a marker of quality/excellence. The question is are they measuring the right things? More recently I heard of something completely new (to me), the K-index (Kardashian index) and finding out what it was about kind of blew my mind.
What are these measures?
The h-index is supposed to measure both productivity and impact. It’s calculated by using the number of papers published by an individual that have a minimum number of citations, for instance if you have a h-index score of 4 you have 4 papers that have at least 4 citations. You may have published 20 papers but they only count once they have reached the minimum citation score. The i10-index by comparison is the number of papers with a minimum of 10 citations, and so is a similar but simplified version.
As of August 2021 my scores for these benchmarks (as taken from Google Scholar) are:
I had on the other hand had never heard of the K score or Kardashian index until recently. The K-index is a measure of someone’s scientific productivity in relation to their social media score. It is determined by dividing the number of social media followers someone has on Twitter by the number of citations they have in peer reviewed publications. In my case (as of the 10th August) that would be 4939/703 = K-index of 7.03.
What’s in a number?
But what do any of these numbers actually mean. For the h-index a score of 20 for a scientist of 20 years experience is supposed to mean they are successful, 40 is outstanding and 60 is exceptional. Obviously these vary between disciplines, but as I haven’t reached my 20 years yet I’m OK with my 16. For the i10-index, only really used by Google Scholar, for a similar level of experience an i10-index of 25 is considered to be pretty good. Again, this varies between disciplines. It is also likely to differ between settings, as a Clinical Academic I am unlikely to achieve the same metrics as one of my academic colleagues, as I also hold a clinical role.
“I propose that all scientists calculate their own K-index on an annual basis and include it in their Twitter profile. Not only does this help others decide how much weight they should give to someone’s 140 character wisdom, it can also be an incentive – if your K-index gets above 5, then it’s time to get off Twitter and write those papers”
Hall, N (July 30, 2014). “The Kardashian index: a measure of discrepant social media profile for scientists” (PDF). Genome Biology. 15 (7): 424.
What is it that my K-index means then? Well my K-index is above 5 and therefore apparently means I may have a higher following than my scientific research credentials indicate I deserve. If I had a low K-index (i.e. 1 or 2) it would suggest that perhaps my science was being undervalued. This was actually seen for a quite a few female scientists in this rather tongue in cheek study.
Just call me Khloe
So I am a Kardashian, it’s official! Now if I could also be given their pay packet and I also wouldn’t mind someone who would follow me around doing my hair and nails – although that might be a little weird on ward round.
In all seriousness there have been a number of things that struck me about this as a concept.
The idea that scientists only attract followers in order to share their own science, rather than to share and discuss science or to raise awareness of the profession
That all of these measures try to claim they measure impact but all they do is measure the equivalent of ‘shares’ by scientists to scientists and I would suggest that that isn’t actually a measure of impact – just a measure of how well you are surviving at publish or perish
The lack of perceived benefit from science communication undertaken by scientists in comparison to the requirement to produce new publications. This has been seen in a bias against women in the promotions process as they are usually disproportionately involved in activities such as outreach, which are not perceived to have equivalent value. Only ‘hard’ science counts
What does the existence of this metric tell us (even jokingly) about the relationship between science and science communication?
I am aware that the author of this paper said in 2022 that it was satire and a dig at the use of a metric indicators, but I think it goes deeper than that and sheds light on a much larger set of issues and attitudes.
I have been told my people that I both respect and who are very senior that I should do ‘less of my nonsense and focus on both my science and clinical skills’. The nonsense they were referring to is my education and outreach work, work like the Nosocomial Project. The impact of this work in terms of recruiting future scientists, about the democratisation of science, and impacts on decision making, definitely aren’t captured by the number of citations I have on Google Scholar.
I think these metrics also fail to capture things like translation into clinical practice, inclusion in guidance and use by groups who may not be publishing papers, and therefore are not citing your work, but have applied it to their setting. That is the reason that I publish, to support change, not to chase a h-index, and so these metrics represent only a very traditional view of academic impact.
As for the K-index, as far as I’m concerned my research is funded by the public, the results therefore are owned by that same public and there is an onus on me to share with then what their funding has paid for, discuss with them whether they actually feel it brings benefit and where it can be improved for those with lived experience. I think the time of academics living in an Ivory Tower and only communicating with each other should be over. Yes we need to talk to each other, collaborate and inspire each other, but that shouldn’t be as far as the conversation goes.
There is obviously a difference between being a science communicator and a scientist who communicates science. The JD’s and the skill sets are over lapping but different. That doesn’t mean that scientists shouldn’t be out there talking about science with the wider public. I feel very strongly that sites like twitter shouldn’t be a single sided conversation. I’m not just going to talk about my science, I want to discuss and amplify content produced by others. I want to have, sometimes challenging, discussions in order to show that science isn’t about absolutes.
Communication on social media is about so much more than the sharing of data. It is a way to develop networks, show support and amplify, as well as to communicate information that is real time and may not have gone through the academic peer review process, such as guidelines or funding calls. So maybe instead of putting scientists with a high K-index and low other scores into academic purgatory we should look at developing a different way to evaluate the modern version of what it is to be a scientist. A score that could capture all of the invaluable work a lot of academics do to ensure that there is a workforce of the future and to support scientific literacy and co-production beyond the Ivory Towers in which we live.
Anyway, apparently I’m off to the paper mines to prove my academic worth. I intend to continue to smuggle out tweets whilst the WiFi permits however, because as much as its lovely to talk to scientists and people like me, science is more valuable when it is truly shared and available to everyone.
Many of us spent a glorious evening last weekend watching the Lionesses (England Woman’s Football team) finally ‘bring football home’ by winning the European Championship. If you don’t watch or have no interest in football this is significant as it’s the first Championship win for any English football squad in my lifetime and something that the male side failed to replicate last year. Listening to some of the commentary made me reflect on the power of winning to support change and why outside of sport sometimes winning can make some of us feel so uncomfortable.
I’m going to put this out there. I get called competitive A LOT. If I’m in, I’m all in. Not for the winning but for the being part of the process. For me it’s all about the learning and the growth. I’m not therefore so competitive with other people but I have a tendancy to, perhaps, push myself a little hard. I come from a family of super competitive siblings, my brother cannot stand to lose and my sister was a superwoman, she was going to start a PhD with a newborn afterall. So I suppose I grade on a curve and when compared to them I was always the one who was happy to lose at cards/games. Still, I was raised in an environment where every dinner discussion was basically debate club and so I carry that with me.
Growing up in this environment means that being competitive is a trait in myself that I’m not particularly comfortable with. Frankly I don’t think it’s a very attractive part of my personality. It does mean that I can single mindedly focus on task though, which has advantages for exams etc. It was interesting therefore for me to see the winning of something being talked about as a really positive thing, not just for the winners, but to enable and support change. Change not just in attitudes but in the way things actually work. I’ve always told myself it’s the taking part that counts (and I stand by this) but is winning something that does enables us to achieve change beyond ourselves? If it does, is this something we should think differently about and actively use more if we are fortunate enough to have it happen to us?
Winning can be seen as superficial achievement, but is it?
Winning something, especially on a large scale, has the capacity to change us. I’ve been thinking about the difference that change makes in us that might enable us to then support the wider change we want to see elsewhere.
There are some people who have an innate confidence that they are where they need to be, there are others who are over confident and come off as arrogant. For the vast majority of people I speak to however, we spend a lot of time striving and reaching to feel like we deserve to be where we are and to belong. It struck me whilst I was watching how much these girls are likely to be the same as me. There’s been a lot of ‘well they are only girls’ and ‘when it comes to it they’ll crumble’. When you’ve spent year after year hearing words like that, I’m not sure that winning is superficial. I know that for me having concrete markers of achievement, especially when given by or measured against my peers, really helps me feel like im doing something right and increases my sense of purpose and belonging. We shouldn’t need external reinforcement but when you have worked so hard having that acknowledged by those you benchmark against matters. It can change the way you feel about yourself and quieten some of those inner voices of doubt, at least for a while. That change in ourselves can embolden us to action, to feel more able to make the change for others, to feel worthy enough to enter the fight. So maybe winning isn’t as superficial for some of us than I had previously thought.
Why does visibility matter?
‘You can’t be what you can’t see’ (or become aware of to be less ableist)…….for me one of the amazing bi-products of this game is that I am writing this blog or more widely that people are talking about it. I’m a Aston Villa fan so I am used to supporting teams that win little and I am certainly not the kind of girl who switches her loyalties in order to follow success. I do get however that winning draws people in. There will be a lot of people who have never watched women’s football who watched that game. There will be a lot of people who don’t normally watch football, or maybe sport at all, who watched that game. Those people who aren’t normally reached, who aren’t normally impacted are now part of a conversation that might have happened anyway but with much smaller numbers. Winning may not just have changed the conversation but also changed the reach of that conversation. Girls who may not have thought that sport was a career option for them will now know that it is something that could be on the list. Wider than that though, girls who have heard that they will never be able to compete on the same stage as men in general will now have evidence that is just not true. The change that can be born out of that one moment in history has the capacity to impact beyond sport and that really matters.
Why am I sometimes ashamed of winning?
Worse than being seen as superficial, winning can actually be seen as an act of selfishness. I’m sure that this is true for a lot of men too but growing up in a competitive household it was still not seen as a particularly gracious trait to talk about winning, you won and you moved on to the next thing. I think on a wider level there has always been that thing that good girls are seen and not heard, you don’t rock the boat, talking too much about success is seen as rubbing others nose in if rather than a way to inspire others. This hit home for me as last week when the Lionesses won I was in a bit of a quandary about whether to share my own success. I was lucky enough to be on The Pathologist magazines 2022 Power List. This is really nice but also as there aren’t that many Clinical Scientists on it I wanted to share it so that more people are aware of it, so next year when nominations open we can work to get more of us nominated.
It came up on my LinkedIn and I stared at it for ages trying to decide whether resharing it was an act of indulgent arrogance or not. Then I went on the twitter and I saw the joy with which other were sharing their listings. So I decided the right route was to share and congratulate everyone I saw who was posting as well as my own. That felt right to me as it was about joining in the celebration of others and working together to try and raise awareness of the wonderful scope of our profession and the list itself.
Like all things the why is important
The why, therefore, to me is as important as the winning. Why was I involved to begin with? What were my motivations? Why am I choosing to share or not what the result was? I think one of the things I often challenge myself to do is share as many of those things I fail at as I succeed at. To remind myself that failure is not shameful as it is often where I get my best learning. I have to challenge myself that if failure is not shameful than succeeding should also not be shameful. As long as I’m being equally visible with both then I’m not doing it for the wrong reasons. My reasons for sharing winning and success should never be to stand on a pedestal and go ‘didn’t I do well’ but to stand where I can be seen in order to offer a hand up to others. Sharing success is not an intrinsically selfish act or an act of arrogance that should elicit eye rolling.
The other way that I reflect on whether success is something to be shared is to challenge myself about how I would respond to it if that post was coming from someone else. I love seeing and resharing the success of others on Twitter and other platforms. I get joy from seeing others succeed. If I get to the point where I am not amplifying others, hopefully more than myself, then I would need to really start questioning why I am putting info out into the world. At that point I feel I would have slipped into self congratulation rather than doing it for the right reasons and I hope I would stop and give myself a talking to.
Haters gonna hate
Having said all of the above let’s just get a reality check. Someone is going to hate whatever you do. That’s just the way of the world, especially as you work to raise the visibility of yourselves and others. The Lionesses are already getting grief and are being told that their success is worth less as they are women. In my opinion this is just more reason to celebrate and push for change. I have been told that my success makes others feel uncomfortable and that I’m only a Lead Healthcare Scientist in order to laud my success over others, that I’m all about winning. The thing is that all of that only matters if its true. If it is true then it gives you the opportunity to reflect, to change and grow. If it’s not true then no one else knows your motivations and so they don’t know your why, they therefore can’t really judge the results.
So my thoughts are that winning can be just as important to others as it is for you. Sometimes the winning itself can empower you to make a change happen far more widely than you would have been able to do otherwise, either due to increased visibility or just feeling worthy to have a voice. We will always be judged but that isn’t the reason to not play the game. Just make sure that you take the time to check in with yourself to know that whatever the outcome you’re doing things for the right reason. If you are lucky enough to win, shout about it, celebrate it, just make sure you celebrate others with the same energy and enthusiasm that you use to celebrate yourself. Winner is not a dirty word.
Anyway, I’m off to the Commonwealth Games this weekend to see more amazing individuals push themselves, break records and win. I may reflect a little more as I admire everything they’ve given to get to this point and you can be sure I will be celebrating them, win or lose, with every step they take.
I count myself super fortunate to be able to share with you a guest blog this week from Francis Yongblah, Higher Specialist Scientific Trainee and Laboratory Manager at GOSH. Anyone who reads this blog regularly will know how passionately I feel about being seen for our whole selves and so it is really special to me to share Francis talking about the importance of Pride in enabling individuals to feel seen and accepted. I hope by sharing this to celebrate Pride month it will help share his important message even further.
“2-4-6-8 – science doesn’t discriminate, 4-3-2-1 – Science is for everyone” – 13 years later, finally getting to be the true me.
A bit about me before…….
I had come out as gay when I was 20 years old at university when I was studying Biomedical Science. I had only at that point come out to my friends. I was terrified to come out to my family, particular coming from an Asian culture and background where being gay was not a common thing. After graduating from university I had got my first job as a trainee Biomedical Scientist.
A few months into my new role I was quite friendly with my colleagues. We all went to lunch one day, and I remember being asked “so do you have a girlfriend” I had responded “no”. The next question was “what’s your type”. At this point I felt my insides turn out as I felt so nervous and anxious to say that I was gay. I was so worried I would be judged and people would not treat me the same as before. Eventually I was able to speak and mutter the words “well I’m gay and interested in guys” at this point my colleagues said “cool, what kind of guys do you like” I felt so at ease and it was so nice to feel that I could be me. Not all experiences I have had in the work place have always been so positive. Although some of my colleagues knew about me, not everyone else did.
A few weeks later, I remember being in the lab when I heard one of the MLA’s talking with another colleague about someone in another department. She had said “hey….I did not realise that guy was a pufta” I started shaking in anger but also in fear as I didn’t want to be judged or labelled in my work place. We spend most of our lives at work and I want to feel safe and comfortable and most of all, be able to be me. I was still young and decided I’m not going to say anything. Reflecting back I regret that decision and wish now I had gone over and said something.
Another negative memory that will always be with me was when I was at a retirement meal for a colleague. Drinks were flowing and everyone was in good spirits. Everyone was free and had taken their work hats off to be themselves. It was near the end of the meal that a colleague had come over to me, put their hand on my shoulder and said “In future, you might not want to laugh like a little girl”. At first I was in complete shock about this, what were they trying to say? Don’t be me? Don’t be gay? That incident really shook me up and made me always feel that I had to have two separate hats. My work hat and my personal hat.
When I was at work I would never disclose anything to my colleagues about my personal life unless I was particularly close with people.
One question that gets asked is “Do we need Pride?” my response…..YES!
The examples I’ve given show that there needs to be support for the LGBTQ+ community so that people can be themselves.
10 years later……We grow!
Getting older you definitely learn and become wiser. I feel that reflecting back on myself I have become more confident and the experiences I have had have not only shaped my character but also given me perspective and allowed me to have that emotional intelligence that is required to understand people and be able to share the same perspective. I’ve since got involve in promoting equality by attending London Pride. I was so proud when my hospital organisation marched for the first time. I felt proud and felt I could be me. It was at this point I was thinking about my professional body “The Institute of Biomedical Science” and getting them to march. I got in contact with the Communications team who thought that this was a great idea and were so supportive. I worked hard to get the application in and low and behold we were successful and obtained a place in the Pride in London march 2021. Unfortunately this was cancelled due to COVID but we were then given the opportunity to march in July 2022.
The build up to this was exciting and heart warming. The IBMS team worked hard to help support the event by coming up with lab coats that we could wear, stickers and little fuzz bugs that we could hand out to the crowd.
It’s time for the healthcare scientists to March!
I was so excited to be marching. My fellow scientists all got ready, dawning on our white lab coats with a rainbow coloured IBMS logo. Everyone looked amazing. We all got ready to march. I remember feeling so anxious at this point. Once we had started to march the adrenaline was going and I started to feel so excited. Seeing the crowd cheer and yell. At this point I felt the need to lead the group and so took to the front of the march.
We were all working to try and come up with a phrase to yell as we marched and then our amazing IBMS communication lead – Matt, came up with the phrase
“2-4-6-8 Science doesn’t discriminate. 4-3-2-1, Science Is for everyone”
I was yelling this at the top of my lungs as it was so loud with the crowd cheering. Our amazing group echoed this. We also yelled “NHS, NHS” and “IBMS, IBMS”
Everyone participated and really integrated with the crowd. Handing out fuzzy bugs and stickers. The irony is that I was at a Pride event and I felt such pride and proud of having my profession represent myself and many other LGBTQ+ individuals and show that within our profession Equality, Diversity and Inclusion is key and that everyone needs to be represented and be proud of who they are. That they are able to be themselves in their workplace.
For the first time in my career as a Scientist, I felt that I was myself and able to be proud to say that I am a Gay healthcare scientist and I am proud of who I am. That my personal characteristics should not hold me back from reaching my full potential. This event will mean more to me as a scientist than anyone would ever know and as we got to the end of the march, I started to well up and cry. I felt amazing but for the first time ever, I really felt that I was me. As I said before, we spend most of our lives at work. I feel I’ve broken that barrier of having to be 2 separate people, the Scientist and the Gay Asian guy to now just being me. I hope that this is just the start of things to come. What has been most inspiring is to see how other IBMS branches and regions have now joined in and organising marches too. I look forward to seeing the pictures from their events and it’s such a good feeling to know that nationally, diversity, equality and inclusion is becoming a key part of being a healthcare scientist.
I previously wrote a blog post called 50 Shades of Grey where I spoke about why I believe we need to do a better job of articulating the fact that a) Infection Prevention and Control is basically 80% risk assessment and b) risk assessments therefore look different in different settings as patients and scenarios differ.
Following on from this post I recorded a podcast with Martin Kiernan as part of the Infection Control Matters series where he reminded me that I said in that original post that I would write a follow up with more details about the components of risk assessment and the different ways you can capture your thinking around them. So continuing what appears to have turned into a bit of a risk assessment themed July here are some of my thoughts about the different ways you can go about developing your own risk assessment framework.
Firstly a disclaimer. The following are things that I have found useful for how my brain works. I hope that others might find it useful but if you do not I apologise, maybe you could share what works for you instead? Then we could have a collective resource around this.
What is risk assessment?
The basics of risk assessment are to understand what risks are present and to put measures in place to decrease those risks. Sounds simple right? The problem is that we throw around the words risk assessment as if we all have the same understanding of what the words really mean, in reality as that concept is applied in different settings or by different professions it can have very different meanings.
a systematic process of evaluating the potential risks that may be involved in a projected activity or undertaking
If you talk about requiring a risk assessment to someone working in engineering or Health and Safety you will get a very different piece of documentation to that I would expect in IPC. Now some of that is to do with the amount of information that needs to be processed in order to come to a conclusion and some of that is about how we convey information. The aim of an engineering or Health and Safety based risk assessment is to give a risk level and matched control measures. The aim of an IPC risk assessment is to support complex decision making. In IPC a risk assessment is more like a framework for ensuring you have taken into account multiple factors in order to support informed action. They are not a one and done process, they are dynamic and can change rapidly as more information is added to the framework. Patients for instance can become more or less infectious, more or less mobile, require more or less intense interventions and outbreaks have information that changes as they develop or come under control.
The use of a framework is nothing new, a lot of medicine and healthcare is based on algorithms we develop during training. The thing is that these are often integrated into our thinking as cognitive processes via experiential learning and we don’t often talk about them. There are two issues with this, one is if we can find a way to visualise or share how we go through our risk assessment framework it can prove helpful to others as they can have access to it without having to fully develop their own. The second thing is that, like anything developed through experiential learning, our frameworks may have intrinsic bias or weaknesses based on the scenarios used to develop it. I am much more likely to dive down a scientific vs ward practice approach for instance. By being able to share our frameworks we can therefore have better conversations with colleagues to both share our thinking and if needed modify our frameworks for future use. The framework itself isn’t static and should continue to develop as we see more, learn more, after all microbes aren’t static and healthcare is ever changing.
What is different between health and safety and IPC risk assessment?
Below is a matrix that I think most of us will be very familiar with and is commonly used in Health and Safety risk assessment. They are based on identifying how likely a risk is likely to be and the impact that risk would have if the incident occured. The thing is that for IPC risk assessments this misses a whole third axis, what are the implications of the intervention on other aspects of that patients care? What are the consequences of controlling this risk for the patient? When we are managing IPC risk we are not always talking about risk from an inanimate object we are often talking about humans that can experience negative impacts from risk interventions. There is for instance data on the impacts of isolation on patient care and also the impacts on staff from cohorting and other measures. I’m not suggesting we therefore don’t need to control risk in IPC, just that a 2 axis table may not be able to capture the complexity of the decision making associated with that risk.
The other difference is the dynamic nature of IPC risk assessments. Although Health and Safety risk assessment should be revisited and reviewed, they are for the most part fairly static. IPC risk assessments can change every time we received new information, results become available, patients become better or worse. Finally, risks in IPC are cumulative, and so the impact of the risk may be low during a 15 minute outpatient appointment but much more significant during a 7 night inpatient stay. All of which mean that a framework that can manage these changes will probably look different to the matrix we are used to seeing.
What are the components of IPC risk assessment?
Below I’ve included some of the key components that I use in my risk assessments and decision making. Overlaid on top of these specifics are always:
Length of exposure
Level of exposure
Susceptibility
Clinical consequences
These always need for each scenario to be looked at bi-directionally i.e. what is the risk from the patient or other patients, what is the risk from the organism to the patient themselves. Even if you’re looking at things like infrastructure or staff the same thing applies. What is my risk of contaminating the sinks with this patients’ Pseudomonas aeruginosa? What would that mean for other patients, visitors and staff? It’s also important to know where or what you are getting your information from? How does that information/data collection method impact the true extent of the information you have? For instance if you are only doing responsive screening you may miss out on asymptomatic carriage vs the information you may have using universal screening. Developing a framework that captures key information is essential but it also needs to be done is a way that acknowledges any knowledge deficits in what is being captured. These are important for the ‘assessment’ bit of risk assessment and impact final decision making. Knowing what you do not know is a large part of the process.
How do we develop a framework that will help us?
Some of the below is taken/modified from a session I gave on risk assessment at the 2021 Paediatric IPC course from the GOSH Learning Academy (shameless plug for the 22/23 sessions below) but the principles apply even if you are not looking at this from a paediatric perspective. Again these are just methods that work for my brain so you may have different formats that work for you.
I think the formats that I find useful to help both the process and to visualise for different audience fall into three main categories:
tabular
question based
flow chart or algorithm based
Each one has pros and cons depending on the amount and variability of the information you are trying to collect and the number of decisions that are open to you based on each piece of data.
Tabular recording
Tabular recording works well if you have electronic systems to record the input data and the decision making based on those actions are clearly defined. A good example of this type of risk assessment framework might be reviewing results for a new MRSA outside of an outbreak setting, and it is very similar to the way that data is collected on the HCAI reporting portal. The benefits of this kind of system is that it is very defined (each field can have definitions linked to it) and therefore it is a good way to ensure the capturing of a minimum data set, as you can require all fields have a response. It is also a good check list for those completing so that items don’t get forgotten. It also permits really good data analysis, you can run reports to see if, for example, everyone with a C. difficile diagnosis had a box ticked to indicate the ward was called and advised to start chlorine cleaning. You can then also run a report against the cleaning order to see that not only the advice was given but whether it was acted on. As a scientist I like this as it removes variability in response, however that inflexibility also reduces it’s usefulness in non standard situations, especially in outbreak scenarios where there may be a large number of possible actions. You can always add in open text fields to record that kind of open data but you then also lose some of the benefits of using this system as you then can’t analyse the inputs easily and you lose the consistency of recording. I recommend this kind of risk assessment framework for complex but standard tasks, where a lot of information needs to be gathered but the number of resulting actions can be captured in a defined list.
Question based
Question based frameworks are (I think) the one that most people working in IPC are most familiar with. You take a call and you work through a mental checklist of information gathering, decision making, and action taking. Even this common tool is often not recorded as a framework that is written down however. When I learnt I did so by listening to calls others took and then having experienced staff listening into mine, pointing out questions I may have missed and therefore data I had not captured. I think even in this scenario it is helpful to have a list of key questions (and sub questions) as prompts or at least a list of framework points to make sure you are capturing key items that would impact your decision making.
There are benefits to this approach, because it is a free framework it enables the capturing of unexpected or non standard information and further exploration of key points. This level of flexibility however does mean that it is possible to go down an information rabbit hole and miss the collection of key information that could have changed the decision outcome. It is especially useful for scenarios where there are lots of possible decision outcomes, such as in outbreak meetings. It also has a downside in terms of the requirement for conscious recording of all data components, which can be time consuming or fail to truly reflect the situation. The free nature of the information gathering can also lead to a lack of consistency between individuals and increase the experiential bias of how scenarios are managed. I would suggest that although this is the most frequently utilised approach it could be improved by having a question frame work recorded so that at least there is a structure, both for data collection and for recording decisions made on the basis of that information.
Flow chart/algorithm based
The main final risk assessment framework is probably the one most of us have become most familiar with following and producing during the pandemic. That is the use of flow charts or visual algorithms. Although in many ways these are the most intuitive for most people to follow they are actually pretty difficult to do well, I know we are up to versions 14+ on some of ours, a lot of those are changes because of guidance, but some are for clarity as it always amazes me how people can read the same info in different ways. This clarity can be especially challenging using this kind of framework as you have to minimise words to make it readable, which can lead boxes open to interpretation and you have no space to include definitions or other wordy items that would support their use.
The advantage of this sort of framework is that it often clearer to describe a process like this than to do so in words, where you would use many 1000s to cover what is shown in a 1 sided sheet of A4. That said this approach is only good for fairly straight forward processes with highly limited variability. The example below comes from a PHE document and despite how much I appreciate the effort that went into creating it, it is clear how easy it is to produce something that is quite hard to follow as soon as the data becomes complex or too many options are available. I would therefore tend to only use this kind of approach with a fairly linear risk assessment that needs to be circulated widely and does not have a high level of decision recording linked to it.
I thought I would mention here the final version of a risk assessment that I use regularly and that is a discussion based assessment. This tends to come after one of the three frameworks I’ve mentioned above and has a whole complexity in itself, both in terms of the decision making but also the recording process. I think I will cover this more separately as it is a slightly different thing but I thought I would just include the below info graphic. If you are going to go through a discussion based risk assessment process (which I think is important, dependent on complexity, to deal with some of the bias and potential for missed info) it is important to pre determine how those discussions are going to lead to decisions and how those decisions will be recorded. It is endlessly interesting to me that different professions will go into meetings with very different ideas about how decisions are reached and so, especially in an MDT setting, there should be clarity ahead of meeting in order to ensure a fair and equitable process.
How can we share our risk assessments with others to aid understanding?
We are re-entering a period of ‘normal’ healthcare where instead of us using a command and control approach, where algorithms for risk are determined centrally and based on test and response, individuals are being expected to return to individual risk assessment for patient care. This is fine but there are now a number of members of staff who haven’t experienced this form of risk assessment enough to have the experiential component, even those members of staff who have pre pandemic experience may now lack confidence due to the fear of consequences in this new world where many of the components of the risk assessment have changed. I’m hoping that by sharing some of my thinking on this we will be able to come together and share some of the frameworks that we use to make risk assessments to support learning, build confidence, identify bias and work towards improvement in all that we do.
Here are the links to the other posts I’ve done on risk assessment including the post the podcast above refers to, one on paediatric risks and one on environmental IPC.
This months posts all have a bit of a risk assessment theme, possibly because I’m back in the land of SARS CoV2 increased prevalence but also because I’ve been contemplating how moving away from a risk assessment led approach to a testing led approach has impacted on how willing people now are to undertake risk assessment. More on that maybe later in another post. What on earth has risk assessment got to do with environmental Infection Prevention and Control? Well frankly it’s the bit that’s often forgotten in terms of our clinical risk assessments. There are also lots of engineers out there making engineering risk assessments for environmental control, and they (for the most part) don’t contain anything clinical. Ventilation and surface transmission have featured linked to the control of SARS CoV2 but I wanted to write something to talk about the environment and environmental risk outside of this, partly because I can’t face writing another SARS CoV2 post for the sake of my mental health, it’s just hard right now.
So back to happier times and how my passion for environmental IPC got started. I joined the IPC team in 2007 after my first three years of Clinical Scientist training. I had a wonderful IPC doctor who was full of vision and aware of the need to increase the scientific technical skills within the team. The thing was that the rest of team wasn’t quite ready to embrace what was a very different approach, all very understandable, at that time IPC was very much focussed on hand hygiene and audits. So I spent some time with the various consultants and it became really obvious to me that there was an area where the introduction of some standardised methodology might immediately make a big difference. Environmental Infection Prevention and Control.
The team themselves were innovative in their approaches to IPC and had embraced environmental screening during outbreaks. The issue with it was there was a one size fits all approach, so organisms were not considered differently in terms of where and how the screening was undertaken. The sampling of rooms and wards involved taking a handful of swabs and just screening places that came to mind. There wasn’t work done on how many swabs needed to be taken within a certain size room in order to have sufficient sensitivity for detection or identification of high risk sentinel sites and how these might need to be changed based on organism. You’re negative predictive value of a screen without these considerations might not be as strong, leading you to incorrectly rule out a role for environmental transmission.
How did all of this work?
My role in the team became very much about how we solved some of these challenges. Undertaking work in patient rooms pre and post clean to define how many swabs needed to be taken. Take too many swabs and you’ll waste resources in both time and consumables, take too few and you’ll end up with false negatives leaving you to miss out on key risks as part of your risk assessment.
One example of this was looking for adenovirus in rooms post clean. Adenovirus can have serious consequences if acquired during bone marrow transplant, and unlike in adults children won’t all have had some form of prior infection. Mortality rates can be as high as 50 – 80%, depending on underlying condition, for a new acquisition. Combine this with the fact that adenovirus can survive in the environment for >3 months and patients can shed loads in the millions via both stool and respiratory secretions you can see that this might be an issue for infection control. I initially started out screening 24 – 30 sites in rooms and then gradually used data from both pre and post cleans to establish sentinel screening sites that are now screened in every room after cleaning to ensure that the next patient is not exposed to environmental transmission risk. We now screen 12 sites, 10 sites was just on the edge of sensitivity, in that if the room failed only 1 site would fail when screening 10 sites. By screening 12 sites if a room fails it tends to fail in 2 – 3 sites which means that the screening isn’t sitting right on the edge of sensitivity.
Even choosing the methods to screen with proved to be tricky, I had to specially develop methods in terms of what kinds of swabs to use, and how to introduce controls that would enable me to understand if the very cleaning agents used to screen were inhibiting my PCRs. Environmental screening is both very similar and very different to clinical processing and so to undertake it properly requires a certain level of work in order to modify the processes to make sure that results reflect actual contamination levels rather than providing false reassurance.
I felt like I’d finally found both my place and my passion. A place where I felt that my scientific background really contributed to the team and could be used to make things safer for patients.
Eventually way back in the mists of time, otherwise know as 2010, I started to develop further some of the work I’d been doing with the team and embarked upon an NIHR funded fellowship looking into the role of the environment in transmission of healthcare acquired infection. The more I learnt about how the role of the environment was considered to be coincidental, the more my own data demonstrated that that just wasn’t true, at least within the paediatric environment. I’ve written just recently about why paediatric IPC is different and the environment and the way that patients interact with it are definitely a big component of that.
I set out to talk to more people from different backgrounds about the questions that I had about environmental IPC, this eventually led to me and others establishing the Environmental Infection Prevention and Control network so that we would have a place to continue to have these conversations.
The first thing we talked about is what is the environment? Is it just surfaces? Does it include the surfaces of medical devices? How do things like water and air fit into all of this. Some of the things I include when I talk about the different categories are below. In terms of medical devices I think of these linked to decontamination, which I will post about at some point. This field obviously has a lot in common with environmental IPC but has been longer established and came about because those items have an acknowledged patient risk, whereas the rest of the environment has been slightly ignored in risk assessments.
Most of the standards linked to environmental IPC are either set by engineers, and therefore are based on infrastructure rather than a clinical risk assessment. The other standards include things such as visibly clean with no dust, dirt or debrie. Admittedly if your surface is visibly dirty it is unlikely to be microbiologically clean but it is also possible to have a surface that appears visibly clean and still has pathogens present, they are afterall…………microscopic and not visible to the naked eye. This means there is a real challenge for IPC teams where they need to work between standards with little guidance to really tackle the role of the environment in transmission……..at least back then in 2010. I’m glad to say that this is definitely changing but it still presents plenty of challenges.
Why is managing the environment so hard?
First and foremost it is the thing that everyone interacts with, patients, visitors and staff and that often no one thinks is s risk. Visitors won’t think twice about putting a handbag on the floor and then putting it on a bed so their friend can get something out. How many times have you seen a WOW or portable equipment rolled between rooms, including highly resistant organisms, and rarely have I seen anyone clean the wheels before it goes into the next bedspace. You can easily see how bits get moved about.
We obviously advise everyone to wash their hands in order to control risk. This means that most people associate sink with being the ‘clean’ items in bed spaces. Whereas in a paediatric hospital up to 60% of the sink backs may have faecal flora as the parents are all in nappies. This means if you do what I have had to do, which is balance a clipboard on the back of a sink to permit hand hygiene, you may have just covered your clipboard in bugs that you will happily move to your next location, your pen, your face. This stuff is hard and the solutions are far from straight forward, especially when you can train staff but many of the interactions are linked to people you can’t easily educate like visitors and patients.
Another reason environmental IPC is hard is that it sometimes breaches the basic rules of outbreak investigation ‘linked in person, place and time’. As you can see from the table below organisms once in your environment can survive for a very long time. That means you may just see single cases split over prolongued periods and so it can be very difficult to recognise you have linked cases, especially if you don’t have access to molecular typing.
Finally, even when you get to the point where you think you have a problem it can be difficult to have an environmental monitoring scheme that can rule in or rule out the environment as a source. These can’t generally be developed well on the fly as part of an outbreak surveillance. They really need to be developed and tested, ideally as part of surveillance systems, outside of outbreak scenarios. The problem with this being is that ut is resource intensive and you don’t even know what organisms might be there to judge the success of your monitoring method. You don’t know the dose and initially inoculum location to judge spread and how well your system is working.
How do we understand this better?
Myself and others have been working to create different types of markers in order to help us gain some direct rather than the indirect evidence that learning from outbreaks gives us.
You can do this is a number if different ways. We are working with an artifical marker developed from cauliflower mosaic virus that then allows us to inoculate different markers across units in single locations. We can inoculate items only touched by staff, or families and then monitor the spread out from this single locations across the units. Because we have control of the dose we are putting down we know how much cleaning/hand hygiene will be required for removal. We also know how long it will last. This means that we can investigate transmission routes and intervention failures in a controlled way to better inform our response to outbreaks, as well as making the whole thing safer by better understanding what we are doing well and where we could improve.
Other people are doing great work with visualisation techniques, both to help people understand risk better but also to work to improve design in order to make things safer before they even get into the healthcare setting.
How has it changed my practice?
Without this work I wouldn’t have the amazing job I have today, but more importantly than that I think our environment would be more risky for patients. When we first started screening rooms post adenovirus positive patient discharge more than 50% of them were visibly clean and met the national standard, but had adenovirus still present (we clean with chlorine that degrades free DNA). We now are also doing weekly screening of the communal areas of those wards as it has shown that we pick up intervention failures by a screening failure, hopefully before it is seen by a patient acquisition.
We have an entire policy that includes how we respond to patient cases linked to environmental IPC. If we get Klebsiella acquisitions we screen sinks responsively as sentinel sites, as we’ve found that if the sinks are negative we don’t find it elsewhere in the environment and its probably a different route. If we find it on sinks then we undertake a wider screen.
We’ve also learnt the hard way that you also need typing to support picking up those grumbling transmission chains and so have done a bunch of work to develop in house typing pathways, still as ever in progress.
Finally we’ve launched ward manuals so that our clinical teams get teaching and have information on how the water and air work on their wards, as well waste etc. Environmental IPC is a team sport and if you don’t work closely with the people that are effectively living in the space you will never succeed at making things safer in the long term.
Anyway, if any of you need a sleeping aid here is my PhD thesis on this topic (health warning it’s long and may not be all that good). Also some of my papers linked to this are uploaded here. Finally, if this has really sparked your interest have a look at the Environment Network website which has more info. I hope you will learn to love the world of environmental IPC just a little and even if not appreciate how important it can be to consider when you are thinking risk assessment.
I’ve been fortunate enough to have spent pretty much my whole career working in paediatrics (children’s medicine) and I’ve already written about why this is so important to me. What I haven’t really talked about before is the thought process that I often encounter out in the real world i.e. that there isn’t really much of a difference between infection prevention and control in adult and paediatric settings.
To really get some of my thinking straight about this I’ve just finished writing 4 hours of lectures on paediatric infection prevention and control. You may be reading this and thinking that this seems like a bit of waste of time as surely the principles of IPC are universal, stop the patient getting infected right? Well yes and no. The principles are the same, as you can see from the picture below, but the challenges, organisms and therefore final risk assessments aren’t (see my previous post on risk assessment here). On a higher level things might look similar but when you get into the detail children and young people are different from their adult counter parts and so we need to make sure what we’re doing meets their needs, rather than giving them the best fit we can manage.
For those you not interested in paediatrics I’m hoping this will just help support thinking on taking a one size fits all approach in any setting and how appropriate (or not) it might actually be.
The organisms that challenge us are different
Many of the organisms that are the focus of mandatory reporting because they cause such a lot of issues for adult patients are not the same organisms that cause most difficulties within the paediatric setting. Two really good examples of this are MRSA bacteraemias and C. difficile. Unlike adult settings I may report a handful of MRSA bacteraemias a year and up to 40% of the under 2’s may be colonised with C. difficile but don’t display any symptoms or go on to develop infection. Therefore these benchmarks are not particularly useful for driving improvements in paediatric settings.
That’s not to say that line related infections are not a problem, paediatric patients are much more likely to interact with lines, play with them, suck on them, pull them out. The lines themselves may also need to be placed in non ideal sites – such as femoral lines in a patient whose nappy wearing, just because of difficulties in getting access. This means that Gram negative line infections, skin flora and yeast may be be more of an issue in these patients depending on the source.
The big thing to bear in mind though is that viruses, both respiratory and gastric, are probably the biggest transmission challenge. Children acquiring viral infections for the first time shed very high loads and often cannot communicate their initial symptoms. This can be compounded by the fact that children may also asymptomatically shed viruses and therefore have no symptoms at all in order to drive specimen collection. Other viruses, such as chickenpox, are infectious prior to the development of symptoms and therefore unless prior exposure to the patient is already known, it may be impossible to prevent exposures to others.
Exposure levels are different
I’ve already mentioned that children may excrete higher levels of viruses when experiencing primary infection (1st infection) versus reinfections, like we experience as adults or in older children. Therefore the level of virus that other patients are exposed to is likely to be higher.
The other thing is that in a specialist paediatric hospital patients may stay for prolonged periods of time or have many repeat visits – leading to not just a one off exposure but cumulative exposure over time. This cumulative exposure increases the chance that a patient will become colonised or infected, it’s all about % conversion chance after each encounter. The risks in a specialist paediatric centre are therefore very different.
The exposure risks don’t just come from other patients however, we’ll talk about staff and carers later, but there are also environmental exposures. Extended amounts of time in hospital expose patients to the healthcare environment in a different way to a single short stay. Risks from equipment linked to water, and therefore opportunistic pathogens, are greater in long stay complex patients. Patient factors that mean they need to stay in specialist mechanically ventilated room are also different in this patient group. The need to monitor and control these factors is therefore really important (check out the Environment Network if you want to hear more about this).
The underlying conditions are different
Working in a tertiary referral centre (specialist children’s hospital) many of the patients we support have complex conditions or are acutely unwell. I’ve already talked about the fact that this may mean that cumulative exposure becomes more of an issue due to prolonged length of stay. There are other things however that mean that they may also be at higher risk of infection. The nature of their condition may mean they have lots of lines and/or skin breaches, meaning they have gaps in the bodies natural protection systems. They are also likely to be on lot of different medications that may cause immunosuppression or in the case of antibiotics, impact on what microbes they have on board. These things will change their risk just by changing what’s going on within their bodies. The more different medications and the longer they are received them, the greater the risk that needs managing.
One other thing to bear in mind is that paediatric patients get admitted with different conditions to their adult counterparts. There are even differences between the different age groups within paediatrics about how they present. You can see the under 1’s present differently from the overs 1’s, once you start getting over 12 the presentations may start to look very similar to those of young adults and so are different again.
The ways patient interact with their own bodies and the things around them is different
So we’ve established that the microbes these patients have are different and that the very things we do to help these patients recover may also impact on their risk of infection. Children are also different in the way that they interact with both their own bodies and the rest of the world.
I’ve been a hospitalised child myself and when I was in intensive care I apparently spent a chunk of time pulling out my lines when I was semi sedated. I’ve had patients who knew the world would come running if they sprayed blood from their Hickman line. Then there are the patients where you’ve had to put (femoral) lines into the artery in their thigh as its the only place where you can get access, but the patient is also wearing nappies and we know that nappies can leak. All of these things can make the line site which is supposed to be kept clean and with limited interactions challenging to maintain in children. The same is true for other plastics and objects that are there and breach the bodies natural defences. They may therefore get organisms from sources that adults are less likely to and these interactions are important to identify when undertaking your risk assessment so that you can take different actions to prevent them from happening.
Interactions with other people are also different for children. When a baby is distressed in hospital, staff as well as carers will pick up and sooth them. Paediatric patients therefore may have prolonged close physical contact with the staff on wards in a way that patients may not in an adult hospital. There is a risk therefore of picking up infections that may have mild presentations in adults but which may be more severe in children, such as whooping cough.
In Trusts like mine where parents stay on site as main carers for their children, there are also a number of considerations linked to infectious transmission to and from carers to their children. This has been a really key consideration during the COVID-19 pandemic where we considered children and their carers a bubble whilst on site. In these scenarios where family are supporting in care provision it can be challenging. Your first line of advice would always be for symptomatic carers to stay away but that isn’t always possible. In a scenario where the infection is transmissible for 48 hours prior to symptom onset then the child has often already been exposed and therefore its about what happens to further reduce risk. Sometimes carers will have to leave site, especially if they are unwell enough to require support themselves, in other cases interventions such as them wearing a mask may reduce the risk enough. Managing the risk benefit equation in these scenarios is something that is probably experienced most in paediatric settings.
One of the other big differences is the way that children interact with their wider environments. Patients with me for a long time will be learning to crawl or walk within their environments, they will therefore be grasping for things and interacting the floor in a different way. Other children will be playing with items on play mats that are by their very nature near the floor. When they throw things (as children do) they may sometimes try to retrieve them and therefore touch the area outside of that mat. I’ve also had many patients in that developmental phase where they will put anything in their mouths, including shoes and anything else within reach. This interaction with the environment is key to development but obviously brings with it extra issues and risks that need to be controlled within the healthcare setting.
Finally in this section I want to talk about toys. Toys and play are essential to development, in fact there the RCN is due to launch some guidance on this later this year that I was involved in developing. Play is super important and can also be key in healthcare to supporting interactions and limiting distress. The right toys and understanding the risks that different types of toys and play interactions bring is a key part of risk management. Wet play for instance is not something that most hospitals would recommend. It’s OK to give out a teddy bear that a patient will take home but not to have one that goes between patients. Books and jigsaws are a no no as unless made of vinyl or plastic they can’t be cleaned properly in between patients. Each toy needs to be thought of separately and decisions made about where it might be most appropriate.
Interventions are different
Some of the interventions we need to think about in paediatrics may therefore be different to adults in terms of managing the slightly different risks. For instance having age appropriate boxes of toys that can be cleaned between patients is the kind of approach that can be undertaken so as to maintain access whilst still limiting risk.
Standard IPC interventions, such as isolation, need to be thought about carefully in paediatric settings. Isolation can impact on developmental milestones as patients will see fewer people and therefore have significantly less access to interactions to support speech and communication development. The balance of this is that if a patient acquires an organism, because others weren’t isolated appropriately, then they will likely carry that organism for a period of years and so the consequences of getting things wrong can impact patients for years
It’s a family affair
One of the key things to remember about paediatric settings is that when you are looking after children you are almost always going to be looking after their families too, in terms of emotional well being at least. When you are putting a child in isolation you are also isolating their carer. This means that at a time of usually heightened stress we are removing a parent from their support network also, sometimes for months at a time. It’s important therefore that we take the time to get to know them as people as well as carers for our patients. I’m as guilty as anyone of calling people ‘mum of XX’ instead of a name. This may have less of an impact if its for 2 days but when you are looking after your child away from other support then losing your name is just another step towards losing your identity. I’ve included the link to a twitter thread here which discusses a little bit about what it’s like to be on the other side of this particular table which I found to be an important reminder.
I hope you’ll agree that working with children is a privilege. To provide the very best in care to this patient group we need to view them as people in their own rights, they deserve us taking the time to think about them and their needs, in a way that is potentially different from other more adult focussed settings.
Anyway, here is the talk that finally came out of the ruminating on this topic, hopefully it might be useful to some of you.
I loved my PhD, it was one of the most amazing things I’ve ever had the privilege of doing in my career. It was also the start of my physical decline, the point at which I developed alopecia and started to have auto immune attacks. It was (next to FRCPath) the psychologically most challenging thing I’ve ever done. I don’t regret it for one second, but there are aspects of what it is like to do a PhD that I think I would have been better prepared for if someone had talked to me about them before I started. Now I supervise PhD students myself and I try to have some of the conversations with them that I wish that someone had had with me.
Completing any PhD is a roller coaster and crossing the finish line is a huge mile stone. There is a lot of road from the start to completion however. So today I wanted to talk about one topic in particular that if I had known about when I started would have meant, when it happened to me, I didn’t feel so alone, out if my depth and like a failure compared to my peers. I’m talking about the second year slump.
Now this post is going to focus on PhDs but a lot of the thinking about why this is challenging and hard can be applied to any form of long term project that is high stakes and mostly undertaken in isolation. There are probably points we can all take away for different aspects of our working lives
So what is the second year slump?
The second year slump is the time during the middle of your PhD when you feel like you’ve lost your way. It’s the time where most students have a massive crisis of confidence both linked to their own skills and whether they can ever complete, but also linked to the project itself and whether it will have value. It is a pretty dark and lonely time where everything feels really hard and very isolating.
A question of timing?
Why does it happen when it happens? The second year is that point in a project when you have been doing it for long enough to understand the scale of the project and are so firmly embedded in it that you see both all of the challenges and all of the faults. You are also still quite far away from seeing the finish line or having outputs that make you feel you are really achieving.
Now obviously the second year slump doesn’t always occur in the second year, when it happens depends somewhat on the time scale of your PhD, it may be later if you’re working part time. The thing is it has happened to every PhD student I’ve spoken to at some point and certainly to every PhD student I’ve ever supervised.
One of the difficult things about entering the middle stage of your PhD is that you are getting to the point where you will be actively comparing yourself against others. Am I doing OK? Am I working hard enough? Am I productive enough? The problem is that every single project is different, your learning needs as a student will also be different as everyone starts in a different place. Therefore comparing how you are doing against others is often a fools errand. To compound this you are often benchmarking against peers that are either super enthusiastic as they have just started, or against other peers who are getting outputs (papers/posters) and meeting their success criteria because they are further down the line. Very rarely do you have someone in exactly the same boat to truly compare against, and yet we are rarely told to not compare against others.
The road ahead is all starting to become very real
The other thing about the middle of any long term project is that you are too far away from the end to truly be able to conceptualise what that looks like, and far enough from the beginning that the true challenges of the task are becoming very real. Rather than being filled with lots of enthusiasm and just an idea that it is going to be challenging, you know know quite how challenging the path ahead will be.
At this stage it can often feel like no progress is being made. The increments are so small that you can’t fully judge the distance you have travelled and you are so fully focussed on what is in front of you that you forget quite how far you’ve come. One of the tricks that I’ve been thinking of doing with my new starters is to get them to write notes to themselves for 6, 12 and 18 months as with a reminder of where they are and what they hope to have achieved by that point. I hope that by doing this it will give them something concrete to reflect back on to truly understand their level of progress. Pairing students during the second year slump with new starters can also actually help at this point. As well as developing them as educators it can also stand to show them how much knowledge they have acquired since they were the new starter themselves.
‘Oh, everyone wants to know about me’
It is a truth universally acknowledge that you should never ask a PhD student how it is going. The main issue with this is, if you are anything like I was at this point, I had very little life outside of work and my PhD so I just didn’t have a lot of small talk that wasn’t about my project. The problem is (and I acknowledge the irony here) everyone has an opinion or some advice. People who haven’t done a PhD have nothing to really compare it against in terms of giving you the support you need. We also all know of those other PhD students who use discussion as a way of making themselves feel better by talking about how great they are doing, whereas in truth we know that they were actually doing no better than anyone else. This is often compounded by your supervisor who will have a 1001 different priorities and will be trying to strike a balance between pushing enough and (if you are lucky) caring enough about your health and wellbeing to not push too much.
During the second year slump it can be tricky to find anything positive to say. You can’t babble on about everyone you’ve just met or how great it is to start, you often have nothing concrete that people will understand (like papers and posters) to share, and in all honesty this phase of an experimental PhD is often just filled with a lot of failure which can be difficult to discuss for fear of judgement. These things can all make just simply answering the question ‘how is the PhD going?’ challenging.
Stepping into your future
Finally, and I know it doesn’t feel like it, this is the point at which you really are developing and learning most. You’re at the point where you are starting to take risks and explore what it’s like to do novel work, you are truly beginning to work as a scientist and that can be scary and require adjustment.
At the start of your PhD you will mostly be doing the ‘safe’ work. Learning techniques and building on work done by others, but not initially taking those next big leaps of thought that are required for you to develop your own work. During your second year you are usually going to be making your own intellectual leaps and so the consequence of that is that there is a lot of failure and trouble shooting as you try and work things out. As you really grow into undertaking work as an independent researcher, you make that shift into following up on your own thoughts and really take responsibility for planning your work. That responsibility and the fact that your success is intrinsically linked to how well you develop into this new role can be truly terrifying, but it’s rarely articulated. Most people think the adjustment happens in the first year, but in my experience it is definitely during the second year when this shift starts to occur.
So if you are feeling low and lonely in the middle of any project, know that it is not you, it’s probably a function of the type of work you are doing. Remember that this is hard and that’s OK as you are truly beginning to reach your potential and anything worth doing is not easy, so be kind to yourself. If you are a supervisor or other form of mentor, talk about this with your students that are coming on board, think of ways to make it easier. Last of all and for the love of all you hold dear, don’t as a second year PhD student if they’ve started on their thesis yet, unless you’re prepared to give them a LOT of tea, cake and sympathy.
girlymicro 