Microbiology (Clinical)

Holding the Line: What it feels like to be seen as the ‘Big Bad I Said NO!’

girlymicro General, Healthcare Science, Leadership, Microbiology (Clinical)

When I was a kid there was a cartoon called Stoppit and Tidyup. It was a kids world where the baddy was the Big Bad I Said NO! This particular post was started during the pandemic when I was thinking about perceptions of the word NO but has kind of lingered as one of those things I wasn’t quite ready to get my head around. The last few weeks have kind of shown me it was still relevant outside of the pandemic however, and so this week I thought I would post about what it feels like to be seen as the gate keeper or to be the person who feels like they are holding the line. In essence, what it feels like to be the person who likes to be liked but who has, as an adult, turned into the villainous Big Bad I Said NO!

I have previously posted about the inevitability of not being liked by everyone, and the challenges of speaking truth to power. The thing that’s unique about becoming the Big Bad I Said No is that it can be a mask/hat/role that is needed in all kinds of settings, and the stakes can vary widely – anything from 1:1 relationships to impacting Trust or wider level decision making. It can therefore feel very stressful to manage, and that stress can be protracted when discussions and scenarios go on for months or longer. Having now spent some time thinking about this though, here are some of my thoughts on the how, whys, and inevitable consequences of saying NO.

Sometimes, it’s all in how you say the words

The word NO can feel pretty loaded. The very use of it often brings a feeling of judgement. Worst still, in a world where as leaders we should be trying to bring people with us, it is the ultimate reminder of hierarchy. As a leader, if I have to go there I will just saying NO can make me feel like a failure, as I feel I should have been able to find an alternate solution or compromise. Also, as a previous recipient of NO, it can make you feel powerless and lead to you questioning your understanding of your relationship or the organisational values.

It is crucial therefore, on both sides, to communicate more than just the NO. NO, without an understanding of the values and drivers that led to it can be pretty destructive. So it is important, although the temptation may be to drop the NO and get out of the room, that it comes with context to support the why.

Sometimes, you need to be direct

Sometimes, being a gatekeeper can be pretty uncomfortable. Interestingly, I find it easy with an infection control hat on versus with a Lead Healthcare Scientist hat, probably because patient safety trumps personal feelings. It can be tempting when you are in a position where the NO is going to be hard or challenging to try to say NO without saying NO. The problem with this approach is that although you may leave the encounter feeling less scarred or exposed, it is likely you are also leaving it with less clarity. Worst than this, not only have you said NO, but you also have taken away the recipients’ opportunity to question and gain a clear understanding for their own processing. It may feel easier in the moment, but you are probably just kicking the problem down the line rather than working towards a resolution.

Please note that this sketch has an 18 age certificate

Sometimes, it’s about being clear that you are living your values

I think one of the reasons that a NO and holding the line is easier (although still hard due to the stakes) in infection control is because it so clearly aligns with my core values, and ones that I hope are represented more widely within the NHS. We should all put patient safety first. Therefore, you can respond in a way that you feel enables you to speak to someone else’s shared values. I hope that the same is also true when I speak to people about equity of access, but in truth this one can be more challenging, as sometimes you are asking people to give up something for someone else, this can occasionally overrule this personal value for the recipient.

Sometimes, it’s harder to make that shared value assumption, and so it becomes especially important to share clearly why you are doing something, both from a factual, but also value perspective. This can include things like wanting someone to be in a better prepared position before they undertake training course X so they can get more out of it by starting with a better grounding. It can also be that a change would be better placed after we’ve set it up using pre steps. It’s important, though, that if it is a true NO, not to fall into negotiation, as that can result in confusion.

Sometimes, it’s about showing someone the big picture

Frequently, when I have to say NO, it’s because I have access to information that the other person doesn’t. This may be information that enables me to have a more holistic view of risk or success. When saying NO in these cases it’s crucial to talk someone through that wider picture, not only because it helps them contextualise the NO, but it may enable them to come up with an alternate approach that might result in a YES. I hope that by taking the time to do this it may result in the recipient being empowered when they leave the conversation rather than deflated. Obviously, that’s not always the case, and sometimes, individuals will need time to process the information. At least by investing the time it offers an alternative perspective and hopefully demonstrates that I value both the person and the dialogue.

Sometimes, it’s about showing your thought process

This one is a little bit of an extension of sharing your values and the big picture. In my case, as a scientist however, it also includes sharing data and evidence and using that to explain how I came to my conclusions. I sometimes go too far down this particular rabbit hole, as it’s my comfort zone, and it does not always work.

Some people will respond better to different things. Some people like me respond to evidence, some will respond to patient led and other values, some are pushing a vision, and others will respond if you share the big picture stuff. Knowing who your audience is helps you pitch, but including a bit of everything in your prep and being able to pivot to what is landing best for greater focus is a skill worth developing.

Sometimes, it’s about being prepared to defend whilst maintaining being open

Despite your best efforts to explain and justify, you like me, may end up being pulled into rooms of people who don’t particularly like your conclusion or what you have to say. This is leadership, and particularly in infection control, it’s kind of what we get paid for. Drawing a safety line and holding it is key. Now, that doesn’t mean you shouldn’t be able to re-evaluate in the face of further information. It also means you should be prepared to defend it. You will need to defend your thought process, your evidence and your conclusions.

I have to be honest, sometimes this is the one I find most challenging. Not because I don’t feel able to justify my process, but when the evidence is clear, I can struggle to understand why others don’t see it. It can also be easy to feel like you’re being personally attacked when it is actually just the scenario. As I wear my heart on my sleeve, I can find it hard though. Trying to take yourself out of the process and focus on the role and the reason you are in the room is something that I’ve found can help.

Sometimes, it’s about finding support

One of the other things I’ve found really helpful is to know where your support lies. In my case, that may be Mr Girlymicro offering me a martini as I walk through the door and telling me it will all be OK. It can be having some trusted colleagues that you talk and walk through your rationale with before meetings. Colleagues that you know may be comfortable challenging you in order to help you see gaps or assumptions in your thought process. Sometimes, it’s about knowing who’s going to be in a particularly difficult room and being aware of where their support may lie, so you know who you may count to support your rationale.

A lot of this is about the work that you need to do ahead of time to build your networks, to get to know other people and their values so you can understand their drivers when you are thrust into a gatekeeping scenario. It can be as simple as moving the dial so you know your unknowns and can therefore better prepare for the unexpected.

Sometimes, a no is actually a not yet

The other thing that’s worth addressing is knowing when a NO is a not now, or not this way. If you can work your way through a scenario so that you can see different routes or avenues to the same destination, it may open a different type of conversation. I’ve mentioned some of these things above, but again, it’s about having put in the time to think things through prior to your response. Often, in infection control, it is tempting to take the path of least resistance, when with extra resource or input, a YES may be possible. Checking ourselves to ensure our motivations are correct is always worth doing and making sure that we are open to the presentation of new ideas or new information that might impact our risk assessment or evaluation is key.

Sometimes, it’s just about sucking it up

Recent years have convinced me that you don’t join infection control to win popularity awards, hardly anyone gives us chocolates at Christmas. The job is hard. Leadership is hard. Saying NO and gatekeeping is hard. The thing is, we do it because it needs to be done. Sometimes, it needs to be done in order to not set someone up to fail. Sometimes, it needs to be done for safety. Sometimes, it needs to be done for equity across your workforce or because of resource limitations. Every now again, it has to be done because the request is just not that reasonable, and the person making it either hasn’t considered or doesn’t have access to the big picture. Denying it’s hard doesn’t get you anywhere. Denying it’s hard can lead you to avoid the hard moments and therefore dilute your impact. Someone has to be the gatekeeper, especially when it comes to patient safety. Someone has to be the Big Bad I Said NO! Some days, that person is me, and despite it being hard I think that the world is just a little safer for it. So know you are not alone, but when your moment comes, be prepared to put on your big girl pants and own the importance of being the person who both says and owns the fact that they said NO!

All opinions in this blog are my own

Celebrating National Pathology Week (Delayed): Talking about routes to registration as a Healthcare Scientist

girlymicro Education, Healthcare Science, Microbiology (Clinical)

I have the best job in the world, and people often ask me a) how I got here and b) how to get here themselves. Now, I have gone a long and circuitous route as you can see below, so I’m not necessarily the best person to ask, although personally I think the circuitous route had quite a lot of unexpected benefits:

That said, when I was a lass the world was much more straight forward with the routes and options being much more restricted and a much greater need to establish your own pathway. There was only one place where you could register, and that was with the Health and Care Professions Council (which even had a slightly different name), where yo reach registration in 1 of 3 ways:

  • Registration as a Clinical Scientist via the Association of Clinical Scientists (route one) – this was the route I followed as a grade A trainee, which later developed into the STP (Scientific Training Programme) as offered by the National School of Healthcare Science
  • Registration as a Clinical Scientist via the Association of Clinical Scientists (route two) – this route still exists and it involves the following ‘those who may not have completed the formal training associated with Route ONE, but have extensive experience in the relevant field sufficient to demonstrate our competences based on a cross referenced portfolio of evidence, and (if approved) an interview.’ This is usually for those entering the field with a PhD who then spend some time working in the role of a supervised pre-registered clinical scientist with the supervision of a registered Clinical Scientist or medic.
  • Registration as a Biomedical Scientist via the Institute of Biomedical Science

All of these routes led to you being registered with the HCPC and the ability to practice as an independent practitioner. The market place has changed a lot since then however and the profession is now filled with so many opportunities and entry points to permit an enriched career progression. So in order to celebrate National Pathology week I’m hoping to answer some of questions about how to become a Healthcare Scientist and sign post to some great resources that others have created.

Although in many ways I still believe the system was great when I joined, it cannot be denied that there were a number of flaws. There was no pathway as such, it was incredibly difficult to move from a starting non-registration requiring position to registration and onwards. Also, once you had your registration there was no structured progression route. It was hard to demonstrate pathways to Consultant Clinical Scientist posts, Advanced Practice posts didn’t exist, and so it was also difficult to demonstrate parity or equity of access. Thus modernising scientific careers was born, an example is below although it’s been through many interactions since. Many aspects of this are still in place, but some like the clinical academic careers route are still being developed, whilst others like the apprenticeships have been developed significantly further. Other entry routes, like T-Levels in Healthcare Science, didn’t exist at all when this was last updated.

This means that anyone wanting to entering the career now has a lot more points at which they can enter, A-Level equivalent (T-Levels), undergraduate, post-graduate, post PhD. There also routes available to move from stage to stage in a variety of ways. Having so much choice can be a little overwhelming however, so I thought I would try (with the help of the wonderful Dr Jo Horne) to collate some of the different info in one place in case it might help.

Apprenticeships

Apprenticeship standards change frequently and are tweaked based on what we learn and the workforce needs. They are great however as they are not only entry points, but progression points no matter what level you are coming in at. The Level 7 apprenticeship will also soon be a thing, and so for a Clinical Scientist like me, training may look a bit more like it did when I was a grade A trainee. They are also great as you can balance progression with your needs in terms of non-work demands, as you have control about when you choose to access them, permitting a lot of flexibility.

Entry Overview Clinical Microbiology and Clinical Virology

Dr Jo Horne has been pulling together some really amazing infographics on healthcaresciencenews.co.uk in order to help clarify not only the apprenticeship routes, but also the direct entry routes into the various formal and informal training programmes that can lead to HCPC registration. She is also actively working with Healthcare Scientists via her coaching website to help support them in their careers and making career progression decisions.

Other Routes to Clinical Scientist Registration

Finally, I’ve previously posted about my experience applying for Higher Specialist Scientific Training programmer equivalence. This is a way of demonstrating that you have an equivalent skill set to those coming out of the HSST programme, which is a formal training programme to support training to consultant level.

There is an equivalent scheme for equivalence to the Scientist Training Programme, but this isn’t the only route to registration as a Clinical Scientist if you haven’t gone through the formal STP programme. I think there is an understandable excitement and engagement with the STP equivalence programme and I am a big supporter of that engagement. I do however think we have to be conscious of the word equivalence. If the STP equivalence process is about demonstrating equivalence to the STP then not everyone will be able to go down this pathway, as the training they have to demonstrate is very broad and, with the new curriculum, very clinical. This doesn’t mean that they should not be able to gain registration as a Clinical Scientist. As I said at the very start, the ACS route 2 existed when I was training and it still exists now. If someone has vast amounts of specialist knowledge and meets the requirement for having practiced in a clinical setting then they may not be suitable for equivalence, but more than suitable for route two via the ACS. I’ve know a number of candidates put in a lot of time and end up being delayed by going for the more well known AHCS route and struggling, when they would have been much more suitable for the ACS route. I think we need to talk more about these alternate routes, and the ones that are available across the profession to recognise advanced practice, in order to support people applying for the right schemes and not getting disillusioned in the process. The route needed will be varied based on the individual but the end point is the same, and we should therefore embrace all of these options.

Hopefully some of these links will be helpful to those of you who are looking to enter this awesome career, and for those of you who are already working as a HCS, maybe they will inspire you to take the next exciting step in your career. Please let me know if helpful and thanks again to Jo.

All opinions in this blog are my own

Would You Like That Explained in Words of One Syllable? Thriving in the world of a mansplainer

girlymicro Academic Life, General, Healthcare Science, Leadership, Microbiology (Clinical), Microbiology (Research), Research/Academia

This post is in honour of international women’s day, I hope by talking about this and sharing some thoughts it will make us all more able to stand up for ourselves and support others in moments like the one below, when we encounter the mansplainer in their natural habitat.

I was at a conference last week, and I was struck yet again by the number of questions that were asked that were commentary and not indeed questions. I paid attention, and, in this case, 100% of those undertaking this behaviour were older men. The reason I started to pay attention was because the first session I attended was filled with a panel of young female scientists. The Chair of the panel, however, was an older man, and when this commentary occurred from one of the attendees, instead of shutting it down, he actively participated and even exacerbated the issue. Not only that, but the commentary was also inherently incorrect and was not even helpful. I must admit I found myself becoming pretty infuriated and later found other women who’d been in the room who found it equally maddening. So this week I thought I would channel some of that science rage into a productive place and talk about survival in the world of the mansplainer.

NB please note I recognise that there are also some women that exhibit these behaviours routinely (and we probably all do periodically). In this post I talk about mansplaining as the behaviour and not linked to gender, unless I’m recounting specific personal experiences.

In the interests of full disclosure, I’ve also had a fair amount of men recently lecturing me about what it is I do and do not know, as well as some ‘interesting’ comments on my blog. I therefore may not be feeling as balanced about this topic as I would otherwise. The thing is, it’s not like it is as unusual as it should be, and you would think, therefore, that I should be less bothered by it. In fact, the opposite is true. Now I’m aware and see it happen to others. I’m even less tolerant. I’m pretty fortunate that it only happens to me 3 or 4 times a year to a level that irritates me. It happened less when I became a Consultant, and I suspect that it will happen less (to my face) now I’m a Professor. Even so, with all of these benchmarks of knowledge and experience, it still happens. So here are my thoughts on living in the world of the mansplainer and how we might all work together to make it more tolerable.

Don’t worry little lady

Let’s start with talking about some classic mansplaining that has happened to me. I’m partly starting out with this because I had a really lovely male boss who just didn’t believe that these things happened as no one had talked to him about it. By putting it down here prior to talking about what we can do in response, I hope to contextualise some of what it’s like for any allies out there who have experienced it less as individuals.

My all-time ‘favourite’ example of mansplaining that has happened to me was an email sent to myself and a female colleague that actually started with the words ‘don’t worry little ladies’. The email in question was sent in response to a query about engineering standards. Now, these days I would respond with ‘that’s Professor Little Lady and I am worried so please explain………and what you are going to do about it’. At the time, though, I was completely thrown by how 4 words could effectively minimise my years of experience, my authority to ask the question, and impact my feelings about my ability to follow up. In my defence, I did follow up and insist on further information and a review, but something so small could actually have impacted my ability to do my job and would never have been undertaken with my male consultant boss. These comments, therefore, are not insignificant when, especially in healthcare, they could lead to a reduction in safety. That said, did I escalate? No, did I forward the email to his boss and explain? Also, no. It’s so normal that it never even occured to me. I suspect if I had, it would have just been called ‘banter’ and waved off.

One of my other favourite things (not really) is when I’m called into a room to have a technical discussion, and when it becomes apparent I’m not convinced by the argument, the room full of men call in yet more men, not to enhance or bring more information to the discussion, but because they somehow believe that having more men in the space repeating each others words will somehow intimidate me or force me into conceding that their science is suddenly correct. I do not enjoy conflict and I generally believe it’s bad form to point out the flaws in someone’s argument in front of others, in a way that could be seen as aggressive or embarrassing for the individual. However, if you pull >20 men into a room to lecture me on, for instance how HPV works, when you are neither a microbiologist or have any experience with viral loading or kill, and think that calling in a further 10 will change the underlying fact that I have just finished writing about it for my thesis, my argument is unlikely to change. All that will happen is that I will cease trying to cover up my level of knowledge in order to play nice and I will quote papers and research at you until you let me leave.

Have you thought about?

One of the other scenarios I’ve found where some interesting male commentary occurs is on some of my blog posts. Now, don’t get me wrong a) most of the commentary I receive on my blogs is super supportive and is what gives me the impetuous to continue to write them and b) I acknowledge that by writing and (over)sharing the way I do I also invite engagement and discussion of the content I put out. Every now and again I get a comment that I don’t approve for public sharing and just leave in the archives as I’m not sure that they are part of the discussion I want to have.

When I posted earlier this year about being overwhelmed and shared some tips that have helped me to get through I received some comments from various male subscribers. These comments were very different from those of my female subscribers, who shared how grateful they were that we were talking about the fact that everyone has days when they struggle and that coping mechanisms are key. These comments all came from a place which I assume was kind and supportive, but ran along the lines of ‘if you feel overwhelmed maybe you should have spent the extra time working and clearing your emails rather than writing this blog’.

On the surface I kind of get it, but also a) it is my right to choose how I spend what free time I manage to have for myself, without commentary from others as long as I’m breaking no laws and hurting no one b) blog writing, for me, has become a method of processing my work load and stress levels and therefore suggesting I abandon it would be removing a key coping strategy I utilise c) the blog post was about sharing experiences and methods to move through feeling over whelmed, not a pity party post about how it sucks, therefore the suggestion that I focus my time on not supporting my community is against the ethos of what this blog is about and frankly kind of sucks and finally d) the assumption that I wouldn’t have considered doing less and not over stretching myself probably doesn’t give me very much credit in terms of self reflection or self awareness. So, I suppose my point is this, sometimes by stating the obvious and your opinion about it, it can come over as pretty patronising, as if it wouldn’t have occured to me and I haven’t done the thinking myself. That said, intent matters, and I don’t believe that these are often meant with any ill intent, so I leave them as unapproved and a source of future consideration and move on.

If you look for it, you will see it

Frankly, some of this is insidious, as I discussed in the intro, I only really started paying attention at the conference because there was such an extreme version of it that it drew my attention and I became deliberately aware of it. Sadly, when I posted about it on twitter the almost universal response was ‘only one’ to my retelling of the male commentator. It’s so universal as a stereotype that we laugh about it, but my thinking is also what can we do to challenge it or support others when we see it.

Summary.   

Role incredulity is a form of gender bias where women are mistakenly assumed to be in a support or stereotypically female role — an administrative assistant, nurse, wife, or girlfriend, for instance — rather than a leadership or stereotypically male role, such as CEO, professor, lawyer, doctor, or engineer. While this slight or mistake might seem innocuous, it can have real ramifications for women. Women must expend extra energy and time to assert and prove their role. Their words may lack the credibility and authority inherent in their position. And when women are not seen as a leader, they may be less likely to be hired into male-dominated roles or to be considered for promotions.

While the real issue of role incredulity is systemic, there are steps organizational leaders, workplace allies, and women themselves can take to prevent and correct it., including setting organizational norms, being an ally, owning your mistakes, and, if you’re a woman, proactively identifying your role.

https://hbr.org/2021/12/when-people-assume-youre-not-in-charge-because-youre-a-woman

I suspect there are few women amongst us who haven’t been asked to ‘sort the coffee’ despite being one of the most senior people in the room, or who haven’t had their bank card saying Dr handed back to their partner. These are little things, and I for one am completely OK with getting coffee, but not because I’m a woman, but because I think we should all take our turn and hierarchy shouldn’t remove us from that. I find it hard therefore to know when to draw the lines over such things, I’m a team player and want to do my part, but I also don’t want to sustain a stereotype that might negatively impact others. Honestly, even thinking about these things in the moment and having that constant dialogue with yourself can be pretty exhausting when it happens over years or decades.

Do these things actually matter?

Even though I feel that I own my place and have so much more strength than I did when I was younger, these comments, decisions, and moments still take up cognitive space. I may rebound more quickly but I still go through the ‘experience-self recrimination spiral-replay’ cycle in order to process it and decide where fault may lie with me or where the learning is.

“What we found was that women largely had negative outcomes as a result of being mansplained to, whereas it didn’t affect men as much,” said Briggs, whose research was published in the Journal of Business and Psychology. “They tended to register that their competence was being questioned more than men did, and to attribute this to a gender bias – so, maybe this person doesn’t think highly of me or doesn’t like me because of my gender.”

This feeling wasn’t shared by male volunteers who were given a condescending explanation by a woman. “Maybe they perceived it as ‘this person is being rude to me’, but they didn’t perceive it any differently if it came from a man or woman, and they didn’t attribute it to a gender bias,” Briggs said.

https://www.theguardian.com/science/2023/feb/03/let-me-mansplain-studies-reveal-negative-impacts-of-behaviour?CMP=Share_iOSApp_Other

It may be therefore that we have to acknowledge the role we play in how we receive the information and the fact that some of the behaviour we experience really does not have any ill intent. However, that also doesn’t mean that those undertaking such behaviours don’t equally have a responsibility to understand how their behaviour impacts others, and in some cases leads to the active detriment of the women who are the recipients. Especially if this behaviour is endemic in institutions/settings or originates from the same individual over protracted periods of time.

So, how do we handle it?

I’ve previously posted about how I learnt to own the place I found myself in with some tips on managing this as individuals. I do think that dealing with direct interactions rather than our own imposter syndrome needs a different set of skills, ones that may indeed help with how we see the world over all. It all starts with being conscious of ourselves in the moment, where do we sit, what do we say when we introduce ourselves, how do we respond in the moment and how do we let our view of ourselves drive these dialogues?

Below are some areas of thinking that have helped me and I hope might also help you in traversing the particular challenge.

Decide which truths to believe

I am often considered over emotional because I wear my heart and values on my sleeve. It’s a running joke within my team that I have absolutely no poker face, and the time to be concerned when in a room with me is when I stop being expressive, as it probably means I have become coldly annoyed.

For a long time, I thought that this was the biggest weakness. I had many a person (male and female) explain to me that I couldn’t be successful as I was and that to proceed I really needed to change and fit the stereotype of what a boss/consultant/professor should be. Well, frankly, screw that. Hiding who we are and pretending to be someone else should not be the only path to success. Being open and honest about my values and who I am is not a weakness. It requires integrity and fairly often bravery to function openly as who you are. We are supposed to be assertive but not too assertive, smart but modest about it, passionate but not emotional. I, for one, don’t want to play that game and, in many ways, just opted out and found ways around it. I strongly believe that we no longer need to play by the rules of those who came before us, let’s set our own rules, let’s choose our own truths and empower the future to be different and better for those who will follow on behind us. Choose your own path and let that be your truth.

Practice makes perfect

Now, I’m not sure I would be comfortable saying any of the below as they are written, I think I would be too scared of coming off as aggressive. For all you women out there who could and own being that assertive, I am not worthy. That said, I have used many of these responses, if not these exact words, in order to manage conversations.

The thing for me is you need to know what language you are comfortable with and practice it before you need it. In the moment I am often surprised and lose my mental footing, therefore if I haven’t practiced how to hold my ground and be assertive I lose it to hesitancy and upset. Practicing enables it to almost be a reflexive approach that you can draw on, so that you don’t have the cognitive additional load of making those nuanced word choices in the moment. So the sentences above may not fit you, but find ones that do and try them on for size well before you need them.

One of the things that also helps me is wearing a different head space when I go into rooms where this is likely to be an issue. ‘Dream’ would never hold up in these spaces, and when I leave them, she often crumbles in the replaying of the moment. Professor Cloutman-Green, however, is much more able to hold her own. It’s almost like my science shield enables me to suffer less from impact in the moment and so allows me to maintain or re-establish myself in that moment much more readily. This is different from not being my authentic self in a space, I am still me, but it gives me the emotional distance to process things later rather than being overwhelmed in the moment.

Self-awareness is key

Ever walk into a room, and there’s a single chair left and you offer it to everyone else who comes in after you? I do this all the time. It’s just polite, right? Absolutely. However, if you are in a room that internalises hierarchy and everyone sitting is a Consultant like you and everyone else standing is more junior, by undertaking this action you are unconsciously giving away your seniority in the room. You are signally you’re difference to your other consultant colleagues. Being aware of your surroundings and what cues you are sending out is important.

Ever sat listening whilst a colleague towered above you? The person who deliberately chooses to lean against your door frame whilst you sit in order to explain X or Y to you. Dominance positioning is a thing, we are primates after all. If we have small and closed body language it says a lot more than our verbal responses in the conversation. Sometimes, when you find yourself in a mansplaining situation the mere act of repositioning yourself can impact the conversation. Stand up, gesticulate using wide body language when speaking. It may be that this merely changes the way you receive the exact same dialogue, but sometimes that is half of the battle. If it also supports you in using some of your practiced dialogue, all the better!

How do we help others?

When sat in the conference room mentioned at the start of this article, I had so much rage at the way these young scientists were being treated. My PhD student who saw and understood my response asked ‘are you going to say something?’. I responded ‘no, these girls are going to handle it’, and they did. They did so perfectly. I think one of my biggest pieces of learning over recent years is not to run in like an amazon warrior to save people, as this can in actual fact be diminishing and takes away their opportunity to act. My response now is to be there as a back up if they signal they need help and to offer support and reinforcement with ‘you were amazing in how you handled that’ afterwards to let them know how successful they were from an independent observer view. By rushing into save we can be as bad as the mansplainer as it indicates we don’t have faith in their ability to handle the moment. That said, if I’d had an official role, such as Chair, I feel it would have been my responsibility to stop the situation from happening in the first place. My take home is this, how you respond has to depend on your role and the situation.

I still love the females from the Obama administration who used their voices to amplify those of other women in the room. Not all actions need to be direct or confrontational, sometimes just being there to repeat the voices of others is enough. I wish that I had been able to breath through my rage and find an amazing follow up question to allow that panel to shine even more in that moment, but I didn’t and that’s my learning. That moment wasn’t about me, it was about them and next time I will have practiced how I can then act to amplify them better in the moment, rather than worry so much about the mansplainer in the room and giving him my energy. Every day I learn a little more.

Right, I’m off to the growlery until I find myself in a better mood. See you on the other side.

All opinions in this blog are my own

Learning to Take Your Place: The path to owning the space you find yourself in

girlymicro Academic Life, General, Healthcare Science, Leadership, Microbiology (Clinical)

I remember my first attendance at the CSO Healthcare Science awards incredibly clearly. It was probably around 2015, and I had been nominated for the Rising Star award (I didn’t win, the amazing Lisa Ayres rightfully rocked it). It was my first dinner event, and I didn’t really know anyone. Everyone was in their finest evening wear, they’d all done their make up, they all knew each other. I remember sitting there on my own and feeling how much I just didn’t fit into this world. When the Lead Healthcare Scientist award was given out (we didn’t even have one at that point) I remember the banter on stage about where the winner had brought their dress from. I wouldn’t even know where my dress was from, at best M and S, not something that would be discussion worthy for over 100 people. I was so aware on that night that this was a world where I didn’t fit in, or have the tools to navigate.

Despite being Girlymicro, I’m not actually particularly good at the getting dressed up thing. I’m not one of those girls who has ‘wardrobe choices’ and saints help me if I have to paint my nails. It’s just outside of my wheel house. I’ve also posted before about how bad I am at networking and how I’ve had to develop coping strategies to be able to feel comfortable in rooms at conferences. I have friends and colleagues who are naturally gifted in this regard, but I am not one of them. I am not ashamed of who I am, or where I come from, I’m a proud brummy girl who has worked hard, but that doesn’t change the fact that in 2015 I stared at out at a room full of people from my profession, supposedly from my world, and just felt as other as it was possible to be.

Roll on eight years, and through some twist of fate I don’t think I will ever truly understand, I find myself standing outside of Westminster Abbey, waiting to go in to witness the Coronation of King Charles III. I have gone through a lot of emotions in the journey to this spot, but when standing here I didn’t feel like the girl who didn’t fit in. I arrived through those doors comfortable in my own skin, proud to be representing my profession and not scared to represent all that I am in the process. So how did I get from there to here? How I did I change and grow to feel like I could (most days) own the space I find myself in?

Honour the reason you’re here

The first thing for me was the realisation of how many people, woman in particular, have fought and sacrificed so that I could have the opportunity to even feel like an imposter in a space. I’ve posted about my mum and her journey to support science before, but there are so many woman who have faced so many challenges just so I would have the opportunity, or the door opened. Over time I’ve realised how important it is to seize those opportunities in order to honour those that came before. To move the dialogue on and to ensure that I leave things more open and equal requires me to do my bit, to make my sacrifices for those who will come after, to go through that open door and wedge it open so that others can follow behind and then take even bigger strides than I will. The cost of my feeling uncomfortable and experiencing self doubt is nothing compared to what those who went before experienced. If I think of myself as part of a wider picture, of just another brick on the yellow brick road, then it becomes less about me and more about the journey, and what I do to support others. That doesn’t require me to know anything about hats, false lashes or designers, that only requires me to be passionate about why I’m doing what I am doing. Suddenly everything else feels slightly less intimidating, after all, I know my why.

Be decisive: decide who you want to be in that space

So, you are not like everyone else, congratulations! I think that may just be a very good thing. When you enter a new world, a new network, a new experience, you have an opportunity to be deliberate in deciding who you want to be. You aren’t carrying the baggage of being know as ‘the new girl’ even though you’ve been there 20 years now. You aren’t that girl who spilled adenovirus tissue culture. You are shiny and new. You therefore have the opportunity to tell your tale, to share your why and really focus on the impact you want to have. Most of the time you have been invited into that space, so try to reflect on why that is and what you want to achieve. If, like me, you want to move the dialogue forward than it is OK not to be like the other people in the room, you have probably been invited into that space for just that reason. Don’t lose sight of who you are because of the newness, see it as opportunity to be the essence of what you want to bring into that space. If you can focus on why you have chosen to be there, rather than being overwhelmed by the choices of others, then I find it very grounding. For me, that reason can be anything from, I came to have 1 conversations with X that I couldn’t have other wise, to I came because I want to raise awareness of Y. Sometimes, for me, that can just be me actively introducing myself as a Healthcare Scientist and opening the door for people to ask me what one of those is, so I can discuss how awesome this work force are.

Acknowledge your fears

One of the things that has helped me most is to not just ignore my fears and pretend they don’t exist, but to spend time in reflecting on why they exist and what triggers lead to them overwhelm me. For me, it’s often about letting people down, or standing out in the wrong way – thus diluting my message and meaning I lose my voice. For the Coronation, because I knew not feeling like I was fitting in appearance wise would be a trigger for me and therefore not achieving the representation I wanted to achieve, I took steps before I went. I researched what to wear, I learnt to understand the dress code. This meant on the day I didn’t worry about that part at all, I could just focus on representing IPC and the Healthcare Scientist profession, this isn’t hard, because I have the best job in the world and love my profession. Suddenly I’m freed up to focus on joy and not fear. In 2015, I hadn’t done this work and it’s not something that happened over night. I had to take the time to learn more about me so I could then manage my responses. The work is worth it though. Obviously, this doesn’t always mean you won’t be taken from left field, but most of the time if you’ve put in the work you can free yourself up to be present and enjoy the moment.

Understand that the world is not you centric

The other things is, and I don’t want to ruin anyone’s egos here, you’re just not that important. The BBC did not care what I was wearing at the Coronation, in 2015 I was probably hardly noticed at that event, let alone anyone bothering to think enough about me to judge my outfit or elevator pitch. Frankly, we are mostly just not that important to other people. Therefore a lot of the fears we have about being judged are really not that relevant, we’re just not that seen. Also, even if the worst happens, and you spill that red wine all over the carpet at the House of Commons drinks reception (yep, I did that) the likelihood is that no one will remember. In my case the only person who remembers is Professor Mark Fielder, mostly because I almost spilled it on him too, and we just laugh about it now. I have been to some truly awful conference presentations, but I remember the topics, I don’t remember the speaker. Even if the worst happens, when you get over the mortification, you will be the one that remembers it, it is unlikely that anyone else will. So be braver, the worst is probably not that bad, spend less time worrying over it and embrace the good that could happen instead.

Have the bravery to keep being you

Finally, and this may be because I’m just growing old disreputably, but be brave enough to be you. You find yourself in this moment, and no matter the reason you arrived at it you are the master of your own destiny. Be brave enough to bring all of you into that moment and be who you want to be. It’s not always easy in the moment but I promise you, you will regret the moments when you wuss out and toe the party line or try to be someone else so much more then any moment when you were truly yourself, no matter what the reception. For me, I guess its always about having honesty with myself, and building relationships with others based on the trust that I will be seen. Relationships and moments built without that honest and courageous authenticity will never be really real, you’ll always question them and yourself within them. By being who you are then, good or bad, what you create with others is the truth and has real meaning. I feel it is only by being bravely who we are that we can have the impact that we want for our lives and for changing the world for those who will come after. So lets raise a glass, to being authentically and completely us, and celebrate all that we are, both the good and the work in progress!

All opinions in this blog are my own

An Unexpected Invitation: Representing the Healthcare Science & IPC workforce at the Coronation of King Charles III

girlymicro General, Healthcare Science, Leadership, Microbiology (Clinical), Science Communication

Please note, this is a rather self indulgent post written to help me remember in future years what was a truly spectacular day and set of events.  Please forgive me and feel free to skip.

Let me start off by saying what an incredibly normal person I am.  I have a job I am passionate about, friends and family I love, but apart from quite how fortunate I count myself to be, I am incredibly normal.  I don’t have ‘connections’, I didn’t go to private school, and neither I nor my family are part of any clubs or other exclusive societies.  So imagine my outright shock when in March this email dropped into my inbox on a Friday afternoon:

This is a joke………right?

On the 31st January 2020, I was fortunate to be awarded the British Empire Medal for services to healthcare and I wrote a little about how I didn’t believe it in a blog post.  That was a fascinating process in itself, especially as I couldn’t tell anyone. When this email dropped into my inbox however, frankly it felt like someone was playing a bit of a joke.  I opened and returned the form, almost on auto pilot because it felt like the kind of thing you should do, but as soon as I hit send I phoned my mum and Mr Girlymicro and had a bit of a breakdown after I calmly got the words out.  Just saying the words ‘I think I’ve just been invited to the Coronation’ put me into a complete spin.  You see, I’m the girl that snuggles down with a cup of tea and Agatha Christie when I manage to get time off, or to be completely honest, some truly awful reality TV (hated by my husband 🙂 like Love is Blind.  I am not the girl that gets invited to fancy dinners or big events, let alone something to be seen on the international stage.  Writing the Girlymicro blog is often the most down time I get on a weekend.  So after sending my reply I sat back and just assumed that they would at some point realise their mistake and life would carry on.

Costume drama

As time went on and more emails went back and forth it gradually hit me that I may, in actual fact, need to attend the Coronation.  I went through a period of properly freaking out about how I wouldn’t fit in, and how I’d have nothing sensible to say, my family pointed out it was too late for that, I’d accepted the invitation.  I was locked in.

Then I proceeded to have, what a dear friend, referred to as a ‘Costume Drama’. Now, I get up in the morning and dress in the clothes in front of me.  I am guaranteed to have covered myself in food/tea/detritus within an hour of dressing.  I don’t wear makeup, and when I do I am lucky to not poke my own eye out with my eye liner.  As the reality dawned on me, it also occured to me that I was going to need to have something to wear.  Bear in mind that when I went to the Garden Party at Buckingham Palace I had a tail spin because I had never brought a hat and I just didn’t know what to expect. It took me 6 months to find something to wear and I had a little less than 6 weeks to get this sorted.  This also felt like a complete level above what I had needed to achieve for afternoon tea.

I have previously posted about how I feel about clothing expectations.  In this case, I began to increasingly feel like clothing would have a role as armour, as a way to step into a space where you felt like you needed to put your best foot forward.  I needed to find something to wear that would help me feel like I deserved to be there and could occupy the space I had been given.  At the same time, I wanted to balance the costume with who I am, I wanted to feel both like I belonged and still feel like me.  So, being a scientist, I hit research mode and pulled together as many sources as I could to find the ‘uniform’ that was likely to be worn at such an event, and then to find ways to modify it so I could ‘fit in’ and still be me.  I know some of you will be reading this and feel disappointed that I was not prepared to stand out. To make a statement.  Sometimes, I feel that the freedom to make a statement comes from a position of privilege.  Not always, sometimes it’s merely bravery and not worrying about the consequences.  In this case, I didn’t feel I wanted to make a statement, I don’t feel like I come from a place where I have enough privilege to go against the tide. You may think it shows a lack of bravery, but the last thing I wanted was to stick out in anything but a ‘that’s a nice dress’ way.  I was nervous enough, and a lot of those nerves stemmed from knowing that I was representing not just myself but all of you, my family, my profession, and my friends.  What I wanted most was to make everyone proud, and so standing out needed to be done in the best possible way by rocking a look that acknowledged the event and still felt like me.

Feeling the weight of representation

You see, as time went on, I became more and more aware that the invitation I’d received wasn’t really about me, it was about us.  I didn’t get a BEM for my work in isolation, it was for the work we had done as a community, I was just lucky enough to be the one who got a medal pinned to her chest.  As the event drew nearer, I was so aware that I was representing both Healthcare Scientists and Infection Prevention and Control on an enormous stage.  I am so proud to be part of both of those groups.  I am prouder than I can state about my profession, a profession that is so often hidden and doesn’t get mentioned at the big events.  I knew that the one thing I would be able to do on the day was talk about it and shine a spot light, if even just to a few people, on the amazing work my colleagues do and the sacrifices that they all made during the pandemic.  I was aware that even though it was my name on the invite, in point of fact, in many ways, it wasn’t about me at all.  I needed to use this unique opportunity to shine that spotlight on the people who deserve to be seen.

Coming, ready or not

Knowing it wasn’t really about me didn’t stop me from feeling nervous, however. I often get in my own head about big moments or events, especially things like this that feel too big and outside of the normal, for someone as normal as me.  At times like this, I like to remember a quote of one of my favourite TV series:

“Bottom line is even if you see ’em coming, you’re not ready for the big moments. No one asks for their life to change, not really. But it does. So what, are we helpless? Puppets? No. The big moments are gonna come, can’t help that. It’s what you do afterwards that counts. That’s when you find out who you are. You’ll see what I mean.”

Whistler – Angel Season One

My family, friends and colleagues did a great job of helping me get out of my own way.  I really struggled at first with people asking me why I’d been invited.  I didn’t know, I didn’t have an answer, but with the help of those around me I practiced an answer I could use on the day, ‘I got invited because of the great work that IPC and Healthcare Scientists did during the pandemic, coming together to really make a difference for children and young people, in terms of not only testing but also in keeping them safe in healthcare.  I’m representing a great group of people who all go above and beyond every day, and I’m really honoured to be invited.’ I was as prepared as I was going to be.

A fairy tale day

So, the day arrived.  I continued to be nervous, but I had all the lists and instructions to make me feel prepared.  In the end, everyone I have to say was simply wonderful.  I had been prepared for the formality, but I don’t think I had been prepared for the nice bits, the bits where we laughed and the bits where the event was in some ways just like every other event, just bigger and shinier, and with some of my hero’s present.

The day started at 5:15 am.  I knew that there wouldn’t be many bathroom opportunities and so I could only have one (yes, that’s right, one!) cup of tea.  Because I also knew that doing my hair and make up would stress me out and I wanted to enjoy the day, and because London has people who will do this for a very reasonable price at 6am, a wonderful lady arrived to make me feel pretty.  I was made up, hat on and in a taxi by 7:45.  All the time, with the news running in the background saying people were arriving and making me feel like I was already late.

I had that strange anxiety, like getting to an airport, where you just want to get through security and take your seat.  I have to say that from the minute I showed my invite and started walking from Victoria Gardens down towards the Abbey, everyone was just so lovely and the nerves started to fade.  Security was easy, and the atmosphere just felt really special.  I felt like I do when running a half marathon, when everyone on the side of the road cheers you on, with less running and more hat.  This part was made even nicer by running into another IPC legend Clare Johnstone as I was nearing the Abbey.  This was great because not only did I have someone to experience it with, but we could also take a photo of each other to record the occasion. 

Clare and I weren’t sitting in the same area, so I made my way to find my seat, just behind the North Quire.  I was in some way saddened to realise that I wouldn’t have a good view of the procession, although to be honest, I’d not been expecting one.  What I hadn’t expected was that everyone from Rishi Sunak to Ant and Dec would have to walk right by me both before and during the ceremony, as the Quire was mostly blocked with performers.  This meant I got to do some grade A up close people watching in the 2 hours plus you had to be seated prior to the arrival of King Charles III, including Lionel Richie being a complete gentleman as he went by, asking how I was doing and saying he like my dress.  The other thing that was interesting to note was that everyone had to scrum for seats.  Now, as a pleb I’d expected this to be the case for me, but no, it was also the case for those much more famous than I.  Those entering through the West Door had reserved seats, but everyone else was very much equitable in terms of finding your own within the section you had been allocated to.  I found this somewhat pleasing.

We all knew the toilets were going to be locked down at 10am, and having been sitting since 8am it seemed sensible to try to get a visit out of the way as there would be no further opportunity until after 13:30.  I state this here because, although the event was spectacular, the fact that toilets are always an issue somewhat amused me.  There were 3 female toilets for the entire of the Abbey, for everyone from Hollywood celebrity to little old me, it made no difference.  My colleagues have often heard me swear I will never use a portaloo, as I hate them from an IPC perspective.  The available toilets were a step up, but they were still just temporary toilets.  Of the 3 cubicles available, 1 did not have a working lock on the door, and 1 was blocked, only leaving 1 toilet in reality for everyone to use.  Also, the cubicles were small.  Normally, this would be less of an issue, but as I’m not someone who has often tried to negotiate such things with a rather large hat, it was challenging.  Toilets are an issue, even if you are a King.

When the ceremony started I was fortunate enough to have found a seat next door to the seating reserved for the Heralds.  This was very cool as I got to see them process, but also got to sit and get an up close view of all their regalia and to see a lot more of their roles.  The advantage to being off to one side and therefore not quite on camera was that although the event was still very formal, I got to enjoy some informal moments that made us all laugh.  Some parts of the order of service did not quite go as planned, such as the Prince and Princess of Wales entering iut of order. Because we were in quite close quarters together there was a real sense of comradery, which I hadn’t expected, as we all got up at incorrect points or couldn’t work out when to sit down when things were not quite as stated.

There was also some slight drama, when during the first hymn, the older lady next to me tried to drink some water, choked and then vomited water all down her, me and quite a chunk of the floor.  Trying to silently signal and collect tissues, check she was OK and clean her up was significantly easier given where we were seated, but again our whole section silently pulled together to try and help.  This is the disadvantage of telling people that bathroom access is limited, as over 5 hours is a long time for some people to not feel like they can drink.

There was never really a dull moment during the service, and it felt like the congregation were constantly involved in small ways during the service.  The moment when the enormity really struck me however, of where I was and what was happening, was during the singing of the national anthem, it made me choke up a little, it just felt truly historic, it really felt like I was living through a never to be repeated moment, and I felt so lucky to be there to witness it.

And then it was over, and yet somehow the time after the Coronation itself felt like the nicest bit.  You could almost feel the collective sigh of relief, and the atmosphere suddenly became much more informal, with people taking selfies with each other, talking and introducing themselves and mingling much more freely.  At this point I could really talk to people about the amazing work my colleagues do and what an honour it was to be there.  It also meant I could get a couple of pics of the Abbey in a way you weren’t permitted before the ceremony.

Then, as I was leaving the Abbey something happened that really made my day.  I got to leave the Abbey and walk with Dame Judy Dench and Sir Kenneth Branagh.  I mean, I didn’t have the courage to say anything, especially as they were just talking to each other in a really normal way, but I got to wander down the road with 2 complete legends, and then say hi to Stephen Fry.  The only way I could have been  more excited was if I’d gotten to meet Michelle Obama, but it appears she didn’t get an invite.

It was a truly magical day that exceeded all my expectations, I got to talk to people about the work we do, I got to feel part of history, and I got to visit a world, however briefly, which I never believed would welcome someone like me, and yet it did with open arms.  I felt like I was welcome, I felt like I was seen and unexpectedly I felt like I deserved to be there.

My 7 seconds of fame on the BBC, plus the legend that is Dame Judy Dench again!!

Carrying your family with you

My friends and family mean so much to me, and they properly stepped up to the occasion, from sending gin minis for after the service that I could use to celebrate, to sending me pieces of jewellery that I could wear on the day and therefore carry them with me to help me deal with the nerves, and to help me feel like I belonged.  They helped me move from feeling worried about the need to represent people and a profession who mean so much to me, to feeling the joy of doing the same.  They helped me stay in the moment and understand that rather than fearing letting people down, I should celebrate making them feel seen.

Seeing their excitement, feeling their support for me stepping onto this enormous stage and celebrating me embracing all of who I am and where I’ve come from made all the difference, and no amount of drizzle could dampen the day.

I was collected by my husband Jon after the ceremony, and not only did he bring me an umbrella, but he also brought me comfortable shoes to switch into. I’ve rarely loved him more. Sharing the build-up and the day with people I love, as well as seeing the responses on social media, really did make it a day I will never forget. Thank you for sharing it with me.

All opinions in this blog are my own

Learning to Live in the Grey: Moving back to a risk assessment based approach for IPC

girlymicro Microbiology (Clinical)

This is the post I was supposed to get out last week but didn’t quite make it as my mind latched onto dealing with what was directly in front of me, rather than being in a more conceptual space. That said, after having just run a course, where the main theme was supporting participants to be able to use frameworks to make risk assessments, it still feels like an important conversation to have. Now, these are just my observations and thoughts. They are not meant to be criticisms of any person or indeed the system itself. I hope it will just continue the conversation about what serves us and our patients best, and we all know there is not a one size fits all approach.

Pre-pandemic it felt, to me, that there were guidelines frameworks out there, particularly linked to things like Carbapenemase Producing Enterobacteriales (CPE’s), but in the main part Infection Prevention and Control (IPC) teams used a lot of personal judgement and experience to determine routes to management, with input from Health Protection Units as needed. The pandemic led to a big switch, where a command and control approach was undertaken. This made complete sense, as resources were restricted and shared across the system. Therefore, frameworks supported us all practising in similar ways and with expectation setting. They also supported large scale evidence collection to improve interventions. We were also in a scenario where some of the diversity of what we were dealing with was removed, in terms of IPC, the focus was mainly on one key organism. Now we are moving back into ‘business as usual’ both in terms of patient flow, and in terms of organisms, that one size fits all approach feels like it may do us a disservice, as the challenges are now so much more diverse. We therefore need to think about how me move back to a much more risk based approach, where instead of having a single organism focus, we also take the setting and the patient into consideration.

Risk assessment and risk based decision making

Those of you who have read some of my other blogs, about the fact that I genuinely believe that IPC is 90% risk assessment will not be surprised that I believe that we need to empower people to undertake these risk assessments better. For 3 years we have given everyone very specific instructions for their actions on every part of the pathway, when to test, what test to use, what PPE to wear, all possible because we were focussed on one thing, much like the standard risk matrix below: risk = SARS CoV2, and all risk mitigations are rated against this in a 2:2 matrix.

We are moving back to a world where, instead of using a matrix where everything is measured for it’s efficacy against against a single pathogen, we need to consider multiple pathogens, their characteristics, and how these play out differently in different patient populations and in different settings. Therefore a standard risk matrix approach does not serve the outcome of increased patient safety we all want to achieve.

Sadly, it also gets even more complicated. We have been living in a healthcare system for the last 3 years where everything, action wise, felt like it was determined by testing and test results. That means that we have been functioning using a test based action algorithm for a very long time. Now, I’m a scientist, and therefore love a good diagnostic test. However, in healthcare there are so many things that can impact on test outcomes: timing of the sample, factors such as antibiotics, quality of the sample, test requesting accuracy, specimen type etc etc etc. We are not just optimising all of our testing pathways for improved sensitivity in relation to a single organism, we are trying to use the best choice we can in order to maximise information output for a wide range, there will therefore be things that bias the accuracy of those results. So we are back in a healthcare world where we need to stop being so focussed on the test and the test result, and start seeing the patient in front of us again, irrespective of what the negative test may say. We need to move back from a test based approach to a symptom based approach. If my patient has respiratory symptoms, they should be in droplet/airborne precautions, irrespective of what the test results say. If my patient has diarrhoea, then we need to put them in contact precautions irrespective of a negative gastro panel, unless you have clinically evaluated other reasons for the symptoms. This clinical evaluation step is key, and you can’t put all of the information linked to that in a flowchart, therefore we need to switch from command and control responses, to supporting the experts at the bedside to use their clinical knowledge to evaluate patients, and support them in better risk based decision making to support IPC. We have to acknowledge that the assessment process is complex, but also feel that we have supported staff enough to be able to make those complex judgements.

https://hbr.org/2022/08/solving-tough-problems-requires-a-mindset-shift?

Acknowledging the uncertainty in the system

The problem with a risk assessment based strategy, managed primarily at the bed side, is two fold. Firstly, you have to be prepared to support with the education to enable it to succeed and to know when to escalate and question. This can be time consuming and it is a task that needs to be continuously supported, as staff, patient mix and environments change. Secondly, we have to have honest conversations with staff to help them to understand and become more comfortable with some of the principles of uncertainty. This is because algorithm based approaches often offer, sometimes unreal, certainty. If I do A and then B in compliance with a flow chart everything will be alright. By increasing complexity in decision making, you also introduce uncertainty, and that needs to be acknowledge and addressed as part of our approaches. Otherwise staff will never feel empowered to take the steps required.

Types of uncertainty

The first thing to say, is that not all uncertainty is the same, and therefore you need to approach different types using different tools. Epistemic uncertainty, is the one in healthcare we can probably do the most about. It’s the kind of uncertainty which we can, sometimes, address by asking better questions. Questions like, I notice you seem to be using a lot of tissues, do you have have a cold or feel like you have a bad chest? Questions like, have you been in contact with anyone who has had an infection or been unwell recently? Or have you been travelling a lot recently? If we can support our staff to feel more confident in collecting the information they need, and then knowing what to do with it, they will feel more confident in making decisions without escalating all of those decisions up to someone else for sign off.

Other forms of uncertainty, such as aleatoric uncertainty are harder to address. This isn’t uncertainty that you can address by gaining more or better information, it’s the kind of random chance events that you have to manage by becoming more comfortable with the fact that healthcare is multifactorial, and you may never be 100% about any action or solution. An example I always use in my head for this is a 4 bedded bay where someone has just vomited due to norovirus. We know on the balance of evidence all 3 other patients are likely to acquire norovirus, as it will stay in the air for ~2 hours and up to a million copies of the virus will circulate prior to deposition. What we don’t know is, did 1 of those 3 patients have norovirus last month after a wedding, and therefore currently has sufficient immunity against the circulating strain? Is 1 of the others one of the small number of people who have receptor variance which means they are less likely to acquire infection? You can’t get that information by looking at them, you are unlikely to be able to get that information by testing or asking questions. Therefore you have to manage the uncertainty and deal with the decision making you can undertake, with the information available to you. That decision making also becomes much more complex when consensus making is difficult, and so supporting staff to know how and when to escalate when this occurs is really important.

So how do we deal with uncertainty better?

For me, the first step is to acknowledge that it is there, rather than trying to persuade ourselves that bedside risk assessment is a) easy and b) doesn’t come with any discomfort for the staff we are asking to undertake it. It takes time and space to be able to this well, both for the required educational component and for the staff to be able to have the cognitive space to ask and process the questions, as well as undertake any follow up. It also takes us to really recognise that we are a single team working across that healthcare pathway, this isn’t about IPC putting their responsibilities onto someone else, it’s about improving patient outcomes by having the people evaluating patients as close as possible to the ones making informed decision about those patients. It does not stop the requirement for complex decision making to be escalated or remove the need to be able to ask for support. It also requires feedback and monitoring so that staff do not feel like they are being left alone to carry a risk or fearing consequences for inappropriate decision making. It is about empowerment in patient care, not resource saving.

I personally believe that we need to move away from central dictates for IPC decision making, patients are unique, and combining that with different environments and organisms means that numerous factors need to be taken into consideration if we are to provide the best possible care. That cannot be done well centrally, where we never see the patient and are not aware of the minute by minute changes in their wellbeing. Supporting those at the bedside to make better decisions and empowering them to be the people who respond to those changes is key to moving away from the single organism focus of the pandemic. IPC teams are key, they should be the ones educating, empowering and being the escalation points, but there are simply not enough of them to have one at every bedside and so we need to look at spreading the knowledge and IPC love!

his-dipc-day-2022Download

All opinions in this blog are my own

Guest Blog by Lilian Chiwera: Surgical site infection prevention day initiatives – making change now to help tomorrow

girlymicro Guest blog, Microbiology (Clinical)

I wanted to quickly write and introduce you to the passionate and energetic Lilian Chiwera. Lilian is leading on a new project that aims to raise awareness of and better embed surgical site surveillance in healthcare. Her enthusiasm is infectious and she has swept many of us up in her wake, so grab a cup of tea and read why this piece of work is so important and why we should all want to step up and see how we could get involved.

Lilian Chiwera is a independent Surgical Site Infection (SSI) surveillance & prevention expert with experience setting up and coordinating a very successful SSI surveillance service at Guys & St Thomas’ NHS Foundation Trust (GSTT) from 2009 – 2022. Currently working in Digital Transformation, Lilian is exploring how best infection prevention and SSI prevention can be aligned with current digital transformation agendas. Blogs via: https://www.lilycompassion.com/

“I think I can officially declare that I’m now married to surgical site infection (SSI) prevention! There is no day or hour which passes by when I don’t think about what we can do to prevent avoidable SSIs and promote patient safety in our organisations. Yes, my passion for this important patient safety initiative is overflowing. I am honoured and humbled to have so many people supporting our latest push for SSI Prevention Day (SSIPD) initiatives.”

I must thank Elaine for asking me to write this blog. I have always looked up to Elaine, she is fun, very knowledgeable and always inspiring us through her fabulous blogs. When Elaine asked me to write this blog, I thought… where do I even begin. Elaine coached me on how to write blogs and I have never looked back. Check my previous blogs here and a fabulous selfie I took at the 2022 Infection Prevention Society Conference in Bournemouth, UK.

Given the number of people now supporting these initiatives I thought it was prudent for me to open this up to our SSI Prevention Day Group. I was not disappointed! Everyone came all signed up to do everything possible to support our call to action. It was no surprise therefore when Karen Ousey was so quick out of the blocks to write the piece below, thank you Karen!

Why surgical site prevention?

“Surgical site infections (SSIs) are among the most common and costly health care-associated infections, leading to adverse patient outcomes and death. The continued global discussions identifying the importance of reducing and preventing anti-microbial resistance and embedding antimicrobial stewardship strategies into practice highlights the significance of raising awareness for prevention of SSI for clinical staff and patients alike. Despite there being published SSI guidelines, there is still a lot of work needed to ensure improved compliance with implementation of evidence-based SSI prevention measures. Recently there have been some awareness campaigns that are attempting to raise awareness of wound infection. These include the International Stop Wound Infection Day (ISWID) held virtually on the 3rd Thursday of October annually which embraces Europe, Oceania and the Americas. The campaign features a range of free to access resources relevant to different countries and short videos from global wound care key opinion leaders and recordings demonstrating skills such as taking a wound swab. This campaign led by the International Wound Infection Institute states: Wound infection is a significant problem in both acute surgical wounds, leading SSIs, and non-healing, chronic wounds. Antimicrobial resistance is also a growing public health challenge worldwide which was identified as one of the top 10 threats to global health by the World Health Organisation in 2019. The ISWID campaign has been running for 2 years (2021 and 2022) and has seen lots of interactions from clinical staff across the world through social media posts and people being able to download free resources relating to prevention of wound infection.” Karen Ousey

It’s clear from Karen’s piece above that there is already lots of work going on around tackling wound infections. My desire has always been to ensure that we promote this important patient safety initiative together! In other words, an annual SSIPD can only be effective if all key stakeholders are involved and actively participate. Key stakeholders include all healthcare professionals and consumers of healthcare – covering a broad spectrum of specialisms i.e., Infection Prevention and Control (IPC) and SSI Surveillance and Prevention (SSISP) societies and collaboratives as well as patient safety advocates, journalists, musicians, quality improvement, human factors experts, psychologists, and many others. I therefore hope to see more stakeholders, in addition to those already signed up (see figure 1) collaborating with us on this important patient safety initiative.

Figure 1: Confirmed and proposed supporters

So, what are we really proposing?

Raise the profile of SSIs via:

  1. An annual SSI Prevention Day (SSIPD)/week
  2. Annual regulatory style SSIP inspection tool that will allow us to monitor surgical safety practices throughout the year via our dedicated SSI champions. These SSI champions will disseminate key findings/learning from inspections and action plans for the following year during the annual SSI Prevention SSIPD
  3. An SSI champion model that will give us an opportunity to standardise existing SSI surveillance and prevention processes in the UK and all countries around the globe through our dedicated local hospital, regional, country, and continent SSI champions.
  4. Proposed SSI champions will span a variety of healthcare professionals and consumers of healthcare. Our ambition is to embrace arts (journalism, music, etc.), science, other IPC branches, human factors experts, implementation science specialists, psychologists, Patient and Public Involvement (PPI) groups and many others to help us raise the profile of this important patient safety initiative.

Figure 2: proposed SSIP champion model and areas of initial focus

Proposed benefits include but are not limited to the following:

  1. provision of SSI/infection prevention expertise from ward to board by compassionate local champions, experienced SSI prevention champions, patient safety and infection prevention and control experts.
  2. Opportunity for collaboration and learning from each other.
  3. Opportunity for Chief Nursing Officers (CNO) and Chief Medical officers (CMO), Politicians and Journalists to champion an important patient safety initiative in the UK and globally.

From humble beginnings

What started as just another tweet in April 2022 has turned out to be perhaps one of the best SSIP campaign I have ever coordinated on social media (SoMe). By October 2022 I was presenting our SSI prevention day initiatives proposals at the largest Infection Prevention conference in the UK. Interestingly, the main reason I submitted an IPS conference abstract was because I just could not imagine myself missing seeing my friend Lisa Butcher being inaugurated as new IPS President. Therefore, I ended up taking the opportunity (aka killing two birds with one stone as some say!) to share our SSIPD aspirations with many conference attendees. Our IPS poster which was produced with input from many of our SSIPD group members was very well received. I left the conference believing that this campaign could become as popular or even surpass successes of the WHO annual Hand Hygiene campaign. Check out the timeline of activities via our Twitter handle here and hashtag #SSIPreventionDay.

Engaging our senior leadership

I presented our proposals to the Head of IPC at NHS England, after being given the go ahead by the Chief Nursing Officer. Engaging senior healthcare leaders and politicians is a critical component of our proposals. This draws from my experiences at Guy’s & St Thomas’ NHS Foundation Trust where with Dame Eileen Sills support, we established a very successful SSI surveillance and prevention service.

Proposed next steps

We held our first ever virtual brainstorm meeting which was kindly chaired by the wonderful, very experienced Infection Prevention Champion and Clinical Director at Gama Healthcare, Karen Wares on the 4th of January 2023. Everyone came ready to brainstorm! Check some of our highlights via our Twitter handle here. We’re planning our next meeting in February 2023, where we hope to consolidate and firm the future direction of our work. We now have a WhatsApp group where we’re ‘bouncing ideas off each other’, have a Facebook and LinkedIn page which you can join and be part of our exciting patient safety initiatives.

Conclusion

We’re proposing a novel patient safety initiative which we hope will bring enormous surgical patient benefits.  We believe our proposed SSIPD initiatives are feasible, given the level of traction gained over a short period. Thank you to our supporters and advocates who got us to where we’re today… buzzing with excitement! They call me the SSI Queen and I think I have lived up to my title on this occasion, with amazing support of course.

Surgical Site Infection Prevention Day Initiatives Group at the Inaugural Meeting on the 4th January 2023

Join us

Get involved by interacting on our Twitter, Facebook and LinkedIn pages

All opinion in this blog are my own

It’s Not All Bad in the World of Infection Prevention and Control: The most wonderful time of the year is approaching!

girlymicro General, Microbiology (Clinical), Science Communication

NB this article was originally written for the Association of Clinical Biochemistry and Laboratory Medicine and published December 2021

There’s no getting around the fact that it’s been a tough couple of years in the world of Microbiology, Virology and Infection Prevention and Control (IPC), but at this time of year its worth reviewing the bits of our jobs that are to be honest pretty awesome.  The bits that energise rather than drain us and remind us of why we love our work. 

Before I go any further, I should probably make a confession and declare that I am a bit of Christmas fanatic.  I’m the person who goes to Christmas shops when on holiday in June and thinks that as soon as November hits Christmas films and music are go!  So it’s probably of no surprise that my favourite IPC event occurs in December as part of the build up to Christmas.  Hopefully, you will also appreciate how great it is even if you don’t love Christmas as much as I do. 

I work in a paediatric hospital and every year the patients are lucky enough to be visited by not only Santa, but also his reindeer.  What does this have to do with IPC I hear you ask?  Well any animals brought onto site need to have an IPC risk assessment as they can be linked to zoonotic transmission of infection and thus pose a risk to patients.  My colleagues’ favourite time of the year is when she gets to do this for the rabbits and ducklings at Easter, but for me the reindeer assessment is very much my favourite.

Reindeer can be a source of ticks, which can harbour organisms that lead to Lyme disease and other tick borne infections, as well as being a source of more exotic bacterial infections (List of zoonotic diseases – GOV.UK (www.gov.uk)).  The reindeer that come to us are captive rather than wild, but even so they are still coming onto healthcare premises and need a review. The task therefore, although a joy, does have a serious aspect in terms of ensuring that the area is properly set up in order to permit the patients to visit, whilst ensuring that they are kept safe and not exposed to any risk.

We work with both the school and Santa to ensure that:

  • All animals are established in an environment that supports safe handling of the reindeer to avoid injury for them and anyone interacting with them.
  • Signage and other provision is made to ensure that there is no eating or drinking near to the animals or their enclosure, to reduce any infection transmission risk.
  • Hand hygiene facilities are available for hand hygiene after contact, especially as the patients will feed the reindeer.
  • Decontamination equipment is available to ensure the area can be adequately cleaned after Santa and his reindeer leave to visit other children.

Last year when we inspected we also had the added aspect of ensuring that Santa was SARS CoV2 free and was protected from any exposures whilst on-site.  This included having Santa complete a health screening questionnaire, including questions like whether he had any symptoms or SARS CoV2 household contacts, such as Mrs Claus, in order to assess his SARS CoV2 transmission risk.  He also needed to wear personal protective equipment i.e. fluid repellent surgical masks, to protect him and the children and young people.

This was a new aspect to the visit that made it more challenging and certainly inspired the patients to be differently engaged and ask questions such as: how does Santa manage to avoid the quarantine restrictions linked to visiting red countries?  and if Santa was vaccinated?  We responded that Santa was of course vaccinated as he had been part of the SARS CoV2 vaccine clinical trials and was therefore an early adopter of the vaccine.  We also talked about the fact that because he could manipulate time, he and the reindeer had plans about how they were still going to be able to safely visit all households and quarantine as necessary.  We also discussed that whilst he was with us we would provide him with personal protective equipment training, in the same way their clinical teams have, to ensure that he is kept safe and also protects the children he encounters along the way.  It turned into a really good way to talk to families about how we use a variety of measures in hospitals and healthcare to keep people safe, and to emphasise that although masks look scary they are actually a really good way of protecting everyone.

This experience brings me joy every year but last year in particular it reminded me that keeping people safe and raising awareness of what we do, does not have to exist in isolation from activities that are fun and engaging.  I love visiting the reindeer, however seeing patients be inspired to ask questions and explore IPC in a way they may not feel confident to do normally, also made me aware that it may be not only a joyous experience but a useful one.  It turned something fun for all involved into something that was also educational and supportive of good practice.  So this year as well as making sure I have enough carrots I will be ensuring that I’ve thought about how to make the most of this unique encounter to make a difference for everyone involved.

All opinions on this blog are my own

Guest Blog by Phillipa Burns: Part 2, the view from the finish line

girlymicro Guest blog, Healthcare Science, Microbiology (Clinical)

In the final of a series of blog parts linked to taking FRCPath parts 1 and 2, the wonderful Phillipa Burns has written a guest blog about her recent experience of sitting and passing part 2 in Medical Microbiology.

Phillipa Burns works as a Principal Clinical Scientist (HSST) at Hull University Teaching Hospitals NHS Trust. She has over
two decades of diagnostic microbiology experience, and is currently completing the Higher Scientific Specialist training Programme, with a planned Doctoral graduation in 2024 from the University of Manchester. As she recently passed the her FRCPath in Medical Microbiology in 2022 she is ideally placed to talk about what her experience has been, especially now the exam has gone back to face to face after several years online.

I read the guest blog by Ren Barclay-Elliot about her recent Part 1 experience; it was so generous and thoughtfully written that I thought the kindest gift I could give back would be a piece on preparing for Part 2.

I must say though that the kindest thing you can do for yourself after Part 1 is to take a break, revive and recharge, irrespective of the result, before reaching for the books again.

Trust me when I say that HSST is a marathon and not a sprint; build your reserves before stomping up the next hill.

The caveat to my gift of kindness is that I only have experience of the Medical Microbiology exam; but hopefully this will still be helpful to other life science pathways.

A little about me

I started HSST in 2018, after 16 years working as a Biomedical Scientist in Medical Microbiology.

I think my career can be best described as “mostly wore a white coat and often wore different hats!”; this is true of many scientists that pick up the hats of quality, safety, research and management.

Entering HSST as a direct entrant allowed me to leave all my previous roles and responsibilities behind and to focus on the completion of the programme; I know that the vast majority of HSSTers are master jugglers who are completing this course alongside another role.

Truly, you are all amazing.

First Steps

Part 1 was the first examination I had sat in 14 years and I was revision rusty; I got by with a little help from my friends and by reading guidance and making short notes.  I knew that this approach wasn’t going to cut it for Part 2.

Decide when you want to sit

Plan the best time for you and be honest with yourself about your readiness and your resilience

Look at what is ahead in the calendar; you will be giving up a lot of time and social events in the name of revision so if you have huge life events on the horizon factor these in.

Even if your sole reason for preferring the attempt to be in the Autumn is that you revise best in the outdoors, then make that choice and enjoy reading in the summer sun

Timing really makes a difference, especially if you have children to factor in. I have small children and I couldn’t sacrifice another Christmas to revision; find your redlines and stick with them.

Find some study buddies

Ideally a small group, 4 or 5,  that covers a range of knowledge and skills.  Studying with a both medical and scientific trainees worked best for me.

You need to like who you revise with and it needs to be a safe space; you will share your worries, knowledge gaps, the things everyone expects you to know but you just can’t keep in your head!

It has to be judgement free and welcoming.

Do not worry if it takes a few groups before you find your tribe; I knew that early morning revision groups were never going to work for me but a few fellow night owls were a great find.

Keep the information flowing with chat groups and emails; it is amazing how much information a determined group can gather.

Be prepared to do your fair share of the prep work; exam revision is stressful – especially towards the end and it really helps if everyone does their bit.

Notes

Part 2 checks your knowledge recall under pressure in the format of OSPEs, SAQs and LAQs.

The whole curriculum is covered; this feels daunting but if you break down the revision into key topics and cover one or two a week you easily get through it.

Most of the exam is skills learnt from doing the day job; they are just “stretched” to cover every series of unfortunate events that can happen with cases. It really helps to reflect on the calls you have had during the day and think “what would I have done if that was a child/drug resistant/linked to another case/pregnant woman etc.,” Let your imagination run wild and really challenge yourself until you reach a layer of confidence with your reasoning and decision making. If there are things missing in your day job, find courses and ask for placements.

Make notes that are aligned to the exam format; covering the clinical, infection control, treatment, public health and laboratory identification elements.

Revision

Team event or lone wolf; your approach has to work for you.

I learnt more with a team, and they added depth to my knowledge; the diversity in the both my study groups was phenomenal – I was always awed by the talent in the room and the experiences that my peers had

The exam covers guidance and it is easy to know what you do in your workplace and why; but you need to know if that is evidenced in national guidance, recent studies – be critical of your own practice and look at the quality of the evidence. Also prepare for situations on the edge of the guidance, the grey areas and when you need an expert consult.

Read around the subject; big studies that have changed practice – challenge yourself to understand the design and outcomes. Social media is invaluable for “Top 10 ID papers this year” and tweetorials.

Be able to write, the exam is 6 hours of handache! I spent the last month of my revision hand writing until I was quick enough to tackle a 3 hr paper. A lamy fountain pen proved to be my saviour.

The Exam

Get to the venue early, ideally the night before.

Plan your route and make sure you have all your ID and stationery in your bag.

Take snacks, the need for a sugar hit mid paper was very real

Take study leave before and slowly ease off the revision so that you are rested; this is really hard to do but it is easy to become sleep deprived and to underperform in the verbal stations due to fatigue

Wear smart casual, but comfortable, clothing – it is a long day

Take time after the exam to decompress and debrief, by this point you will know if your study group are sharers and talkers, respect the wishes of those that just want to forget until results day

The whole experience left me very tired, unsure if I hit the brief; this is completely normal.

Results Day

Have a plan, my consultants checked my result for me! I was horrendously nervous and sleep deprived.

Agree with your group if you are going to wait for people to check in; remember this is a tough exam and fail is just a “first attempt at learning”

Check in with the quiet people, give them time to talk about it and reflect.

Celebrate the milestone, pass or fail, reaching this peak in knowledge is a huge achievement.

HSST is so relentlessly busy it is easy to swap the FRCPath preparation for the other items on the to-do-list; I have taken my own advice and had a little pause to just look back at the progress I have made in the past four years.

I have timetabled in events with my much missed extended family & friends; these became the extras that I struggled to fit in whilst revising and I have put some other books, rather than podcasts, on my audible app.

Tomorrow, my fellowship with the Royal College of Pathologists will be ratified and I can officially use the designation, FRCPath; I have asked others – “When does it feel real?”,  this seems to be a common feeling when you have recently crossed the line. I cannot pretend to be unaffected by the enormity of the achievement, I will be smiling for months (maybe years) and I fully expect to sob with joy when I see my study buddies at the investiture ceremony in February.

My final words are “that if you can see it, you can be it”; be proud of the seven little letters (and the many others you have earned), show your career path and light the way for others to follow.

Plenty of people showed me that this is possible, and to them I am forever grateful.

Check out the other blog posts in this series:

Guest Blog by Karen Barclay-Elliott: Life, the universe and surviving FRCPath part 1 – December 2nd

Your Wish is My Demand: Here are some of my tips for sitting MRCPath in Micro/Viro – November 29th

The Trials and Tribulations of High Stakes Assessments: How I still remember everything about FRCPath – November 25th

All opinions on this blog are my own

Guest Blog by Karen Barclay-Elliott: Life, the universe and surviving FRCPath part 1

girlymicro Education, Guest blog, Healthcare Science, Microbiology (Clinical)

I put out a post earlier this week on my experience of sitting MRCPath or FRCPath part 1, but as, in Healthcare Science terms, I am a bit of a dinosaur and sat mine so very long ago I put out a call for someone to help out who has more recent experience. The wonderful Ren Barclay-Elliott was a life saver and jumped to my aid. Ren is a virology clinical scientist based in the Midlands with an interest in congenital and childhood infections, fantasy novels, and cats. She also has demonstrated she has a generous heart by not only agreeing to write this but turning it around so quickly for the enjoyment and aid of all of you 🙂

It’s Me, Hi!

A quick introduction to who I am and why I’m writing this – my name is Ren, and I’m a clinical scientist in Virology and Molecular Pathology. I completed the NHS Scientist Training Program in Infection Sciences in 2020 and have been working in virology ever since. After a year or so of putting off sitting my FRCPath Part 1 exam, I finally gathered up the courage and willpower to attempt it in Autumn 2022. (Spoiler alert – I was fortunate enough to pass on my first attempt.)

I found Part 1 incredibly dauting for so many reasons – not least of which was the fact it was the first exam I had sat since finishing the STP, and there had been a whole pandemic in the interim! Not to mention it is an incredibly broad exam, and as a virologist I had promptly forgotten about 90% of the bacteriology I had ever known the second I finished the STP. I was given a lot of advice about studying for, and sitting, this exam over the last year, as well as gathering some (possibly questionable) wisdom of my own – I hope that in sharing it, I can make Part 1 a less intimidating prospect for anyone sitting this exam in the future!

The Exam Itself

In this post-pandemic world, many things look a little different to how they used to. Part 1 is no exception – at least for the time being, the exam is entirely online. This can be quite an odd experience for those of us used to huge, drafty exam halls and ominously pacing invigilators. There are certainly a lot of perks to this way of doing things – mainly not needing to travel to physically attend the exam, but also the comfort of being at home and being able to think out loud if you come across a tricky question.

The exam itself is simple – 125 best-answer multiple-choice questions in 3 hours. When they say “best answer”, they are not kidding – be prepared to think “but these could ALL be right!” at least 30 times throughout the exam. Fine-tuning your decision making to be able to narrow in on the most likely to be right is a skill in itself, and one that takes time and practice to develop. I found that practicing multiple choice questions from a few different sources really helped – more on that later! Almost everyone I know who has sat the exam finished well before the time limit and had plenty of time to go back and check their answers a few times.

Help – How and When Do I Study?

So now you know what to expect on the day of the exam. But what about the weeks or months leading up to it? How do you prepare for an exam where the syllabus is just “literally everything you have learned up until now”? How long do you need to study for, and how much time do you need to spend on any given topic? Unfortunately, as with many things in life (and in Part 1 for that matter!), there is no single right answer. I was given the general rule of thumb of starting to prepare about 3 months prior to the exam, but I know people who have spent as little as 2 weeks or as long as 18 months preparing for their first attempt.

Personally, I started off very slowly about a year before the exam – not with full-on studying, but by doing fairly low-effort things like listening to podcasts, making a point to attend MDTs where I knew interesting cases would be discussed, and starting to note down areas where I knew I had a weaker knowledge base and reading up on them whenever I had downtime at work. I started studying in earnest about a month before the exam and found this was sufficient time for me to cover everything in enough detail to feel confident.

AS for how to study – there’s as many correct answers to that as there are people on the planet! However, I have tried to summarise my best advice below…

Find Different Ways To Learn

I have always thought of myself as a very visual learner – come exam season in uni, the walls of my room would always be plastered in meticulously colour-coded mind maps covering every possible topic I could be examined on.

An actual picture of the walls of my bedroom circa March 2017 while I was studying for my MSc exams

However, once I got to studying for part 1, I found this approach wasn’t working so well for me anymore – not least because I don’t think I have enough wall space in my whole house for the number of mindmaps I would have made! For a while I kept stubbornly trying to stick to my tried-and-true method (after all, it had gotten me this far!), but eventually I had to admit that I needed to be more flexible in how I learned. I ended up with a huge variety of methods depending on the topic I was learning and how I was feeling on any given day – printing and highlighting guidelines, writing flashcards, making (and delivering) powerpoint presentations, and teaching my (non-lab-scientist) husband, who now knows WAY more about carbapenemases than you’d expect from a high school chemistry teacher.

Trying out practice questions was massively helpful, both for getting me ready for the multiple-choice question format in the exam, and to give me a way to assess my progress as I went along. I found the BIA LearnInfection resource to be invaluable, as well as the infamous “orange MCQ book” (more formally known as “Infectious Diseases, Microbiology and Virology: A Q&A Approach for Specialist Medical Trainees” by Luke S P Moore and James C Hatcher).

I also found listening to podcasts to be a great way to learn – I would thoroughly recommend ID:IOTS (bonus points for the hosts’ Scottish accents, which really helped to alleviate my homesickness!) and Febrile (bear in mind that this is American so not all of their guidelines are identical to those used in the UK, but it’s a great resource and very entertaining). Both are available on Spotify!

Make It A Game

Let’s face it, studying can be incredibly tedious. After finding myself staring blankly at textbooks for hours on end, barely taking in a single word I was reading, I realised that I needed to make studying fun – or at least, not mind-numbing! I found that games were a brilliant way to re-approach a subject with fresh eyes and remember that I am studying this subject because I genuinely love to learn about it. One of my favourite resources with Microbial Pursuit (https://firstline.org/microbial-pursuit), an online trivia game that my colleagues and I got very competitive over! One question is published each day, so it’s great for doing a little bit of learning every day, or you can dive into the back catalogue if you want a more extended study session. It’s a fun way to test your knowledge across the whole breadth of infection science, and useful for picking up little facts that you may have missed in your reading.

I found this approach really important the closer I got to the exam – it was a useful way to remind myself that learning can be fun and exciting, and I wasn’t just memorising screeds of information for the sake of it.

Create Systems That Work For You

Part 1 covers a frankly enormous amount of content, and it can be utterly overwhelming trying to find a way to cover all the necessary material without accidentally missing things out. There are plenty of ways to split it up, and some may work better for you than others! Some systems that I, or people I’ve spoken to, have used include:

  • Going “head to toe” – learning organisms associated with clinical syndromes starting with brain/CNS infections, then down to ENT, respiratory, cardiac… you get the idea. Don’t forget to include skin and soft tissue infections if you’re using this method – it’s surprisingly easy to forget about!
  • Going through organisms by classifications – e.g. start with Gram-positive cocci, then Gram-positive rods, then Gram-negative rods… you get the idea. This can be particularly useful if you’re struggling to remember things like viral structures – if you learn all of your DNA viruses back-to-back, it’s easier to remember they are all in the same group then if you learn them individually by the clinical presentations they are associated with
  • If you have a lab background, then going “bench to bench” can be helpful – learning about organisms/lab tests/clinical presentations associated with wound swabs vs blood cultures vs tissue samples can be a great way to learn if you have a lab background since you might already unconsciously group things in this way
  • Picking interesting cases – if you have a lot of clinical time and see plenty of cases, then you might come across (or be able to construct) memorable cases that help you to learn about lots of different concepts, from diagnostic tests to antibiotic stepdown choices, associated with a single patient

You may find a system that works perfectly for you first time, or (like me) you may need to chop and change as you go along. I would definitely advise going in with a plan though – even if you end up changing it later, it gives you a good framework to start with and refer back to so that you can be sure you haven’t missed anything.

There Will Be Some Questions You Know the Answer To, And Some You Don’t…

While this seems like a fairly obvious statement, it was one of the most helpful pieces of advice I received while I was preparing to sit Part 1. You are never going to know absolutely everything – there will always be at least one question that throws you for a loop and makes you think “how on earth am I meant to know that?!”. All you can do is make your best guess and then move on – while the exam isn’t unfair or out to get you, it is meant to be challenging and everyone has blind spots – don’t let it faze you, just move on. On the flipside, everyone has strengths as well, and you are likely to find far more questions that make you think “Yes! I know this one!!”.

I had to learn to bear this in mind especially when talking to friends or colleagues who had sat the exam before me – people love to tell horror stories starting with “You wouldn’t believe what they asked about when I sat it…”! There are always going to be questions designed to stretch people and test the limits of their knowledge, but these do not make up the majority of the paper. 

Don’t Stress!

I am fully aware that my friends, family, colleagues, and literally anyone who has been in my general vicinity in the last few months will all laugh uproariously at my hypocrisy when I say this, but try not to stress about Part 1 too much. While preparing for any major exam can feel overwhelming and world-ending, it is not the be-all and end-all, and does not reflect your worth as a scientist or as a person. I know many excellent scientists who are outstanding in their fields who did not pass on their first attempt. While Part 1 is a significant milestone, even getting to the point of sitting it is an achievement to be celebrated, regardless of the outcome. Treat yourself with kindness, take breaks when you need them, and ask for help early and often.

Best of luck to everyone sitting Part 1 in the future – I sincerely hope that my ramblings have been at least a little bit helpful. And remember – at the end of the day, it’s just a test. You will be okay. You got this!

All opinions on this blog are my own

Your Wish is My Demand: Here are some of my tips for sitting MRCPath in Micro/Viro

girlymicro Education, Healthcare Science, Microbiology (Clinical)

I posted about the FRCPath exam last Friday and in response I’ve had some people reach out and ask about MRCPath (or FRCPath part 1) and if I had any thoughts that might help in preparing for it.

Now, I have a bit of a part 1 confession. I sat part 1 in 2007, the exam was in September and my contract was due to end in a matter of weeks, and I had no idea what my next steps might be. In those days you had to work for 4 years to get your registration as a Clinical Scientist, but the training scheme only funded 3. You therefore had to find someone prepared to fund your 4th year, otherwise you dropped off the scheme with no registration and therefore you couldn’t get a subsequent role. I registered to take part 1 in case my contract ended, as I thought it would give me the best opportunity to try and find someone who would pay for my 4th year if my Trust couldn’t keep me. When I registered the exam conditions (as that time) said it was possible to defer the exam, but didn’t really give any more information. Two weeks before the exam my contract was renewed, and to be honest as it was looking likely I hadn’t even begun revising. I was just waiting for it to become official so I could confirm the deferral with the college.

My continued employment confirmed I phoned the college to defer, they said, of course! They also said that they hoped that I knew that although I could defer I would have to pay another £384 (see I still remember it to this day) to sit in the spring. I put down the phone and hyperventilated in the infection control office. I couldn’t afford another £384, I was a trainee who barely made ends meet on less that £20,000 a year in London. I walked out of the IPC office and into see my consultant (John Hartley, always a legend) who looked me in my tear-stained eyes and said, ‘well you’d better go home and start revising, see you after the exam’. My husband told me to hit Foyles bookshop on the way home, and that was that. I cancelled everything for the following 2 weeks, revised for 18 – 20 hours a day, and my poor husband asked me more exams questions than I’m sure he’d care to remember. I sat the exam and passed with (I believe) 80%, but this all means that my pathway to part 1 is probably not the one I would recommend for others. So instead of telling you more of what I did, below are some thoughts about how I would do it if I had to sit the exam over again.

Know what’s expected

Part 1 hasn’t changed much in structure since I sat it, although some of the focus of the question content has been updated as medical trainees are now joint Infectious Disease/Microbiology. There is, as expected, plenty of information on the Royal College of Pathologists website about this, but here are some of the things that I think are important to be aware of. The exam is aimed at people who are fairly early on in their speciality training, so for medical trainees this means those who have spent a year or so as a registrar. The exam itself is a different beast from what I described in my post on sitting FRCPath. It is a single 3 hour exam, consisting of what the college calls ‘best answer’, what the rest of us call a ‘multiple choice’. It covers Microbiology and Virology, as it is the same part 1 for both later FRCPath options. For context, unlike FRCPath, most people I know sitting part 1 prepped hard for about 6 weeks rather than for 6 months before the exam.

I’ve spoken to a few people recently who were prepping for part 1 and they were spending most of their time running case studies and learning a lot of detail about HIV treatment etc. I can only talk from my experience (I don’t write or have anything to do with the exam) but for me that is much more FRCPath prep. I think part 1 is much more about understanding the fundamentals of clinical microbiology: whether viruses are DNA or RNA, single or double stranded, what is the difference between decontamination and sterilisation, what are the key toxins associated with Clostridial species? There is more clinical in it now than when I sat it, and if I can I will find someone who passed more recently to write a guest blog (drop me a line to volunteer), but it’s mostly about identifying clinical risk. Part 1 is a lot about facts and memorisation of microbial characteristics and so books are where it’s at!

Get a current view

This brings me onto my first top tip. Find someone who has sat the exam recently and pump them for information. The thrust of the exam changes from year to year and so to really get prepared you need to get the most recent view you can. No one is allowed to share question information, but they can talk through and prepare you for what the current clinical vs organism balance is. They can also talk you through how much basic microbiology you need to bring into the room, and what the best resources are currently available to help you prepare. Most of your consultants will have sat this exam a long time ago and so you really need to be reaching out to your peers. If you are lucky enough to have a consultant in your department who is involved in writing the exam questions, they are still likely to be restricted as to what guidance they can give, so using your network is key.

Find a study buddy

One of the things that I would recommend for any college exams is that you find a study buddy. I did both of mine on my own, partly because of circumstances and partly because not that many scientists were sitting the exams back then. If you can pair up with someone else you will have a much easier time of it. I think this is probably true for three main reasons:

Firstly, you will probably have different areas of strength and weakness. For part 1, if you are a virologist try to find someone who is mainly a bacteriologist, you will then have a ready-made expert to help you go through concepts and visa versa. Even if you are both from the same main domain you are likely to have different interests. This is likely to help you with splitting some of the prep work. Also, if you are like me, you may only realise the gaps in your knowledge when you are trying to verbalise explanations to someone else and so it helps to have someone you can talk things through with.

Secondly, networks are really important and the more of you there are, the larger your combined networks are going to be. You will use your network to find good resources, have prep conversations and sign post you to key topics or challenges. They are the people you will go to in order to discuss how long you should prepare for ahead of the exam, to send you some test questions if you struggle to access them elsewhere, etc. As I said, you can do this on your own, but the richer your access to these, the easier your prep is likely to be. They may even be able to guide you to places that support funding the exam.

Finally, these exams are periods of high stress, by doing it with a peer you can provide each other with support during the process. Sometimes just having a friendly face to walk into the exam room with can make all the difference, or who you can text ‘OMG what is Citrobacter, I’ve had a massive blank’ when doing your reading. Building these relationships will help you throughout your career, and there’s nothing like shared high stakes moments to help bonding 😉.

Read not once but twice

There is a lot of exam technique that can help in passing both part 1 and part 2, and the sooner you start refining yours the easier it will be. The greatest piece of advice I received about sitting part 1 was ‘read through the question twice so you answer the question they’ve asked, not the question you think they’ve asked’. To be honest, I think this is the reason I passed, not because I am super smart or because I was well prepared.

The questions themselves are sometimes long. There will often be a bunch of information that can lead you to jump to conclusions about the answers the examiners are looking for. Most of the questions will have 4 options for answers. A lot of the time you can easily exclude 2 of them, just by reading the question properly. If you skim read the question though and don’t take a minute to appreciate what they are actually asking you can however go down a rabbit hole in your train of thought and pick one of the 2 that were only there for this reason. Save time by reading each question twice and asking yourself ‘what is it they are really asking me’.

Reading not once but twice also extends to checking the barcode answer sheet (if they still use these). It’s far too easy to get out of sequence or accidentally skip a line. No matter how close you are for time (and to be honest you should have plenty to spare), make time to cross-check your answer sheet at least twice. It will save you from unnecessarily losing precious marks.

Don’t over complicate things

Having said that you need to read the question carefully, there was one other thing that I remember finding really challenging in the exam itself. There was an extended matching question where you had to match the type of organism with the right molecular diagnostic test. I remember looking at the list for ages and thinking, ‘I could make a case for using any one of those for any one of these organisms’. Therein lies one of the other problems. It is possible to overthink your responses if you know too much in an area. As I said before, this exam is aimed at medics roughly a year into their training. If you have been a jobbing scientist for some time there will likely be things that you know in far greater detail than they would. It’s important if you find yourself in that kind of spiral to step away and think what would be the approach to someone just starting out in answering this question, what would the most obvious answer be, and let that guide you. Sometimes you may need to move onto other questions and to then return with a fresh set of eyes.

Go old school

One of the common traps we fall into as scientists is believing that all the questions will be based on the latest techniques. Now, it may have changed, but when I sat the exam there was a LOT of old school microbiology in there. Some it now feels old school as most of us don’t use many APIs and biochemical tests anymore. There is however quite a lot of this information that is intrinsically linked to organism characteristics, and as I’ve already said that is a lot of what this exam is about. So, if I were you, I’d pull some microbiology textbooks (not just clinical microbiology) and remind yourself what a VP/citrate/indole etc, test looks like and what they could differentiate. Remember that parts 1 and 2 are sat by international clinicians and so the exam has to serve a global purpose and reflect widely available diagnostics.

Listen to the advice but go your own way

Now, I’ve just written 2000 words of advice but I suppose this is one of the key ones. You don’t have to listen to any of it. Everyone prepares and studies for exams differently. What works for me may be completely the wrong thing for you. There is plenty of advice out there, and there are many people who will be more than happy to share their thoughts and opinions with you. Only you know what might work for you. If you’re unsure, try out different things in plenty of time and discard the ones that don’t serve you. I’ve already talked about my rather unconventional route to sitting part 1, but I made it work. You will make whatever route work that is right for you.

If at first you don’t succeed

Finally, sometimes these things don’t go your way first time. Sometimes, the questions aren’t what you expected. Sometimes, you frankly just have a bad day. I’ve known plenty of people who did not pass first time, all of whom are excellent in their posts. This can be a bitter pill to swallow for high achieving scientists who aren’t used to failure. Bear in mind however that it is more common in medical exams for people to sit multiple times. These exams are benchmarks for safety, and so there is understandably little wiggle room in terms of marks.

Sometimes, when people fail they close off to that failure and double down, rather than opening themselves up to what it can teach them. If you can, be open and take all you can from it. You will come out all the stronger. If failure happens to you, and I know this is hard, you have to let it go. Sitting these exams is in itself a learning experience. You will gain valuable insight into the exam itself to help you prepare for the next time. You will learn a bunch about how to revise, what to revise and how to read the questions. In short the process in itself will make you better, irrespective of the outcome, if you open yourself up to the learning it can provide.

Resources

There are a lot of great resources out there, and I’m sure your networks will help you identify even more. Below are just a few things I found useful when I was sitting the exam or that some of my amazing trainees have signposted that have been useful to them. I wasn’t involved in creating any of them, so they are just suggestions. As ever, pick and choose what works best for you.

https://firstline.org/microbial-pursuit

Not a resource, but if you want to sympathise with my husband for living with the girl who just won’t stop studying, here is a Girlymicro podcast that we recorded about that very subject.

Hope this is all a little useful and please do drop me a line and let me know how you all do and if you’ve got any advice to add!

All opinions on this blog are my own

The Trials and Tribulations of High Stakes Assessments: How I still remember everything about FRCPath

girlymicro Education, Microbiology (Clinical)

Seven years ago this week, I found out I passed the exam to be awarded Fellowship of the Royal College of Pathologists (FRCPath) in Medical Microbiology. It is still the only exam, other than my PhD viva, where I vividly remember not only how it felt to sit it, but also how I felt both awaiting and getting the results. As others currently await their outcome, I’ve been reflecting on what it was about this exam that means, even 7 years on, it has had such a lasting impact on both my career trajectory and my memory? Also, why did I, as a scientist, decide to sit it in the first place?

For me, it started with you can’t

I’ve started a post that I’ll publish another time about the journey from trainee to Consultant Clinical Scientist, and the joys and pitfalls that entailed. For me, although my path may appear winding, I always knew what I was working towards and had a list of things I knew I would need to accomplish to get there. Knowing what was needed was never the issue. Knowing how to achieve it was often much less clear.

Getting FRCPath is essential to becoming a Consultant Clinical Scientist in microbiology. There are, however, 2 common ways of achieving it, by publication or by exam. I knew plenty of people who had FRCPath by publication, and it was a route that was achievable by me, as I was also on a clinical academic pathway. The problem for me was, however, that I was in a patient facing role, making patient-based decisions over a broad spectrum of activity. To me, FRCPath by publication would have given me credibility in a different way and would not, therefore, have been perceived as equivalent by my medical colleagues. I was just not sure it would fully support the work I was undertaking or aspired to undertake. So it was that I started to think that FRCPath by examination was the only way forward for me.

(Side note – I truly believe that either way of attaining Fellowship is valid. I believe it’s just about the kind of work you are going to do once you have it. That decision should drive your thinking about which is the right choice for you.)

I don’t think I’d realised how many feathers I would ruffle along the way by making that decision. One of the challenges, and also eventual benefits, is that a lot of people will give you advice along the way, and some of it will make you question your decisions. This eventually enables you to have an even greater understanding of your choices, but at the time, it can lead to a lot of self-doubt and require a lot of self-reflection. In this case, I was told you can’t by a LOT of people on the road to even sitting the exam. I was told that you could only pass if you worked as a registrar in a teaching hospital for 3 years. I was asked (even at the mock and the exam) why on earth a scientist should be allowed to sit a medics exams and what kind of job did I think I would get afterwards. In just about every way I was told that someone like me should just give up and choose a different path. Any readers of this blog know how well I deal with those kinds of responses. So, like so many other times, I had my reflections, dusted myself off, and came back with even more determination that this was the right path for me. Determination, however, doesn’t always change outcomes. All I’d done was decide to sit an exam, that was all rather different from passing it.

No one said it was going to be easy

What is FRCPath by exam all about anyway and why do people think of it as such a defining moment? It has changed a bit more recently, especially through the pandemic, but when I sat it, the exam was about 30 hours carried out over 4 days. I’ve always described it as a bit like The Great British Bake Off of microbiology exams, but without the benefit of ending the day with cake. Day 1 included written papers (essays, short answers, critical appraisal). Days 2 – 4 were wet lab practicals, with 9 written exams interspersed throughout the days. You would just be told during these to put down your loop and move to another room where a written paper would be waiting for you. These further written tests included: virology, quality, spots and public health. In my year they were closed book, but in previous years some of these had been open book. Between sessions you would be given new specimens or further clinical information on ones you’d already processed to make further laboratory actions. Doesn’t sound too bad…….right? I didn’t think it would be, or I hadn’t quite conceived of how hard it would be until I attended the mock exam up in Blackpool in June 2015.

I knew before going to the mock that the pass rate was about 40% for the real thing and I knew that everyone described it as the toughest exam they had ever sat. I just don’t think that I KNEW it. The challenges of the exam are hard to describe. Some of them are physical, how many of us physically write essays for 8 hours a day these days. I have a history of repetitive strain injury and so it was interesting to come up with a painkiller strategy that would enable me to perform as well at the end of the day as at the beginning. I was surprised at the extent of the exhaustion. Usually, I prep enough that I arrive at the exam in a ball of flames and adrenaline gets me through the day so I can collapse in a heap afterwards. With this exam you can’t do that. At the end of day one you need to study and prep more for day 2, at the end of day 2 you know there is stuff you need to pick up hinted at in the specimens so you can be more sure you know your stuff for day 3 etc etc. The exhaustion therefore accumulates until (at least for me) by day 4 I was working in an exhausted haze.

The other thing that makes this particular exam challenging is that it covers EVERYTHING. They can ask about any organism, any presentation, any vaccine, any treatment. Part of the reason it was designed that way I think, was to ensure that come day 4 when you are exhausted you can still make safe clinical decisions and spot pitfalls and risk. Normally when you walk into an exam room you have a syllabus that enables you to have a fairly reasonable chance of targeting some of your learning and determining likely content. This isn’t that exam, and therefore a lot of the exam techniques you’ve previously used are not quite as applicable. This one is more about maintaining your calm, being structured and clear in your responses and making life very easy for your examiners, in terms of finding and making your points. You have so little time for each of the components that clarity of both thought and communication are key, and practice is the only thing that will get you there, that on top of all the revision you can cram into your brain. (If useful the link to some of the content I prepped to help with revision in 2015 is here)

The ugly truth of coming face to face with who really are

All of the challenges, physical and mental, are nothing compared to the emotional and psychological roller coaster that you go through. I’ve always been fairly fortunate, in that until FRCPath I’ve never come up against a challenge where I thought I couldn’t conquer it if I worked and applied myself hard enough. It’s why I talk all the time about how it’s important to know you’re why. Your why will get you through when other things fail, your why means that you know quite what price you are prepared to pay and what you are prepared to sacrifice. Everything in life comes with a cost, life itself is resource limited. Knowing how much you value something means you know when to stay in the game and when to walk away. That has been true of every exam I’ve faced until FRCPath. FRCPath forced me to face something different. It’s the first time in my life where I’ve had to look myself in the mirror and ask myself whether I actually had what it takes. Not whether I had what it took to put in the time, to face the physical toll or wanted it enough, but whether I had actually reached my limit. Was this just something I would never be able to achieve no matter how hard I worked, but that I as a person would just fall short. I can tell you, apart from fear for my loved ones, I have never felt fear like it.

Now I’m not telling you all this to put you off sitting the exam, far from it. For me it was a life changing process, not just because of the fact that it changed my career, but because of what I learnt about myself. It made me look myself in the mirror and face something that really scares me………….failure. I can in a logical way sit here and talk about how the things I’ve previously post about impact on how I feel about failure, or how because of what happened to my sister this career means more to me than I can logically explain. The thing is none of that can encompass how I felt when having a full on panic attack outside of the exam room before going into short answers, because it had gone VERY badly at the mocks. Just not being able to find my breath. Knowing I could walk away, and just take the easy way out. Then finding the strength of resolve to make a choice, to press the button on my phone and turn on my ‘get psyched mix’. To forcibly calm my breathing and to walk into that exam room, face my fear and turn over the front page of the exam paper. I learnt more about who I am in that moment than sitting 100 easier or more straight forward exams could have shown me, and for that I am strangely grateful.

Is this the best way to test competence?

The question is, should any exam take you to that place? What is it really testing? I was told that most medical exams involve candidates sitting multiple times, it’s common for people to fail at least once, which with a pass mark of ~40% for FRCPath feels likely. I don’t know for definite that this is the case, it’s just what I’ve been told by registrars who’ve trained with me. It is true that I know many highly competent Microbiology Consultants who failed at least once. The other thing is that this test doesn’t really represent clinical practice. In the real world I would consult guidance and other sources if I had any doubts, competence isn’t just a matter of recollection, it’s mostly how we use that information in practice. At the end of the exam one of the education leads at the college turned around and congratulated us, they said not having quit and making it through 4 days was a success in itself. I do see the value in making sure that those sitting these exams can make safe decisions when they are exhausted, after all most of us will take calls when that is the case. I’m not sure however as an educational driver we couldn’t be doing something better. The exam has changed a lot since I took it, it’s now a one day exam. In some ways I’m saddened by this, it was almost a rite of passage that me and others bond over to this day. I also worry that by removing so much of the lab side of things and reducing the exam hours so drastically it could be pretty hit and miss about the content suiting candidates, rather than truly testing against the curriculum. Anyone who works in education knows that assessment design however drives educational engagement. Although I’m not by any way an expert in this, I do think that high stakes summative assessments have cons as well as pros, and just because I’m sad that the exam/rite of passage is under review does not mean that change is a bad thing.

What happens when there is no plan B?

One of the problems with high stakes summative assessments i.e., those taken at the end of learning and are pass/fail, is that there is often no plan B. This is especially true for FRCPath where there are a limited number of times you can sit it before you are not permitted anymore (x4) and will therefore never become a consultant. For someone, such as myself, who is not from a wealthy background and was being paid a junior scientist salary, the costs associated with this exam could be prohibitive. Sitting the exam was over £1000, that combined with hotel accommodation, books, paying for the mock, meant paying over £3000. I have friends who spent over £10,000.00 in 2 years sitting the exam 4 times. In a world where accessibility matters a financial barrier should not mean that someone cannot progress in their profession. Currently the exam in online and so the barriers are not the same, but the exam fee itself can add up. I needed to pass first time, not just because I couldn’t face losing another 6 months of my life, but because I was pretty sure I couldn’t afford to sit it again. I went all in and came out the other side, but I know of people who have found the process damaging, rather than the freeing experience it ended up being for me. It is an immovable block to your future and failing really does mean that you could be dealing with the consequences for the rest of your career, a career that you will have already invested years into.

The payoff was worth it all

Having been through the process though I don’t regret it for a minute. It is still one of the things in my life I am proudest to have undertaken. It has given me the courage and conviction to fight as I had stared into my soul and knew that this is what I wanted. I wouldn’t be a consultant without it, not just because I wouldn’t be qualified but because I wouldn’t have had the courage to fight for it. I still remember my candidate number, it’s become one of my favourites. I still remember crying uncontrollably when I looked at the website and saw the below, and then sent this screen shot to everyone I knew in order to make sure I hadn’t read it incorrectly.

The other thing to say is that there are lots of people out there who will tell you there is only one way to pass this exam and frankly I don’t believe that is true. The exam is a milestone on the pathway to where you want to end up. In the same way that FRCPath by publication is the right route for some people, you can pass this exam by not being a registrar for 3 years in a teaching hospital, after all, I did. It all depends on what your aspirations at the end of it are. If you work in public health you are probably not aiming to switch to being a Consultant Clinical Scientist doing on call in a district general, but to upskill and improve your clinical competence to continue working in your area. If you are like me with an aspiration to work and specialise in Infection Control in a paediatric setting, then your aspirations will be different again. It is OK to sit the exam and plan with this in mind and to make your own path. Everyone is different and where we want to end up does not have to be the same, nor the path we take to get there. The challenges we face along the way are sometimes more important that the destination. Even when it’s hard enjoy the journey, enjoy the challenge if you can and for sure enjoy the person it enables you to become. Finally, if it doesn’t work out first time know that there is life beyond, don’t let my fear of failure make you doubt that that is the case. We are after all definitely more than the sum of our grades.

All opinions on this blog are my own

A new Girlymicro podcast where we talk about what it’s like for someone living with an FRCPath candidate

Clarity is Key: The role of learning agreements in supporting learner success

girlymicro Academic Life, Education, Healthcare Science, Microbiology (Clinical), Microbiology (Research), Research/Academia

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.

All opinions on this blog are my own

Happy but Struggling: Welcome to my third year of the SARS CoV2 pandemic

girlymicro Healthcare Science, Leadership, Microbiology (Clinical), Microbiology (Research)

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.

All opinions in this blog are my own

Guest Blog: Claire and Sam take over the Environment Network

girlymicro Education, Guest blog, Microbiology (Clinical), Research/Academia, Science Communication

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.

All opinion on this blog is my own

Keeping Up with the Kardashians: Your K score and the uneasy relationship between science and science communication

girlymicro Academic Life, Healthcare Science, Microbiology (Clinical), Microbiology (Research), Research/Academia, Science Communication

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.

All opinions on this blog are my own

Delving Into Risk Assessment: Thoughts on how to develop tools that may guide your thinking

girlymicro Healthcare Science, Microbiology (Clinical)

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.

Risk assessment steps

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.

PHE CPE Toolkit Flowchart

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.

Image by Jurgen Appelo

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.

All opinions on this blog are my own

Environmental Matters: Why are environmental risk assessments so tricky?

girlymicro Microbiology (Clinical), Microbiology (Research)

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.

ipc-in-specialist-settings-april-2022Download

So what do I mean by the environment?

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.

elaine_cloutman-green_final_soft_bound_thesis_for_submission_dated_2015.pdf._redactedDownload

All opinions on this blog are my own

Children Are Not Small Adults: Why infection prevention and control in paediatrics really is different

girlymicro Microbiology (Clinical)

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.

ipc-in-special-populations-geriatrics-paediatrics-immuncompromised-Download

All opinions on this blog are my own

Celebrating National Pathology Week: What is a clinical microbiologist?

girlymicro Microbiology (Clinical), Science Communication

This one’s a re-share of a post from last year but I thought it was still a good one to continue this weeks exploration of roles.

To celebrate this week being National Pathology Week , I thought I should take some time to post about what a clinical microbiologist is. I do this because, when I was at university, I really didn’t know that this career path existed. So here is a shout out to all those students who are trying to decide their next steps. You too will find your way.

When I googled microbiologist this is the first item that comes up

Microbiologists study microorganisms (microbes) in order to understand how they affect our lives and how we can exploit them

Prospects.ac.uk

This seems like a pretty good cover-all description. It goes on to discuss that there are microbiologists in many different areas:

  • medicine.
  • healthcare (I’m not sure how they differentiate this from medicine or visa versa).
  • research.
  • agriculture and food safety.
  • environment and climate change.

I must admit that when I was at university most of the options I encountered were linked to the food and drink industry or pure research. I think that their list missed things like Pharmaceuticals (although they may count that as medicine) and other forms of production, i.e. cosmetics.

At university I only did one module of microbiology (I was reading Zoology) and that module was about environmental bacteria and plating out bacteria onto agar plates to see what grew.

How did I go from Zoology to Microbiology?

I really wanted to work in an area of science where I could work to make a difference. I wanted to work somewhere that I could see that difference being made. Working in research felt too abstract to me. When I discovered, through a friend, that I could become a scientist in healthcare I knew it was what I wanted to be.

The National Careers service says you need to have two to three A-levels to become a microbiologist, plus a post-graduate degree. That is mostly true. However, in a world of apprenticeships and T-Levels, that is no longer the only route.

When I became a Healthcare Scientist I became a Clinical Microbiology trainee. So, what was the difference between that and what I’d done at University? The main difference with clinical microbiology is that I focus on organisms that cause infection: parasites, viruses, fungi and bacteria.

I also discovered that there was so much more to microbiology than agar plates. Although – don’t get me wrong – agar plates are still a mainstay of life within the bacteriology laboratory.

One of the techniques I learnt to love was polymerase chain reaction (PCR), which enables us to look for the DNA or RNA of a microorganism instead of growing it. Viruses and parasites don’t grow on agar plates and bacteria and fungi may not grow well if exposed to antibiotics or if present in low levels. PCR allows us to diagnose patients with infections that would not be diagnosed otherwise, or to speed up the process so patients get put on the right treatment faster.

Variable number tandem repeat typing of Klebsiella pneumoniae

PCR also enables us to do things that are harder to do using traditional bacterial techniques such as culture. The picture is of patterns that are like bacterial fingerprints so that they can be clustered into similar groups. This enables me, as a clinical microbiologist, to tell whether bacteria within the same species are the same or not. This is important when deciding whether a bacteria has spread from one patient to another. It helps in acting like a hospital detective, which is a lot of my work in Infection Prevention and Control.

As a trainee I spent four years rotating within laboratory settings. I spent one year in a molecular laboratory, diagnosing patients using PCR. I then spent six months rotating between benches (each sample type has its own laboratory bench) in bacteriology: wounds, respiratory samples, faecal samples, blood cultures, urines, fluids (cerebral spinal fluid etc.) and the primary bench where samples were put onto agar plates. Six months in virology, a year in research and time in food and water, parasitology and mycology (fungal) labs.

The diagnostic process is pretty similar in principle between the specialisms:

  • collect specimen from possible site of infection.
  • select the most appropriate test to detect any organisms (agar plate for bacteria, PCR primers for viruses, etc.)
  • evaluate whether the result (positive or negative) is accurate and whether there are other tests that should be done, i.e. further characterisation of positives such as antimicrobial sensitivity.
  • decide on treatment or management of the infectious cause, i.e. antimicrobials or non-antibiotic management such as surgery.
  • advise on infection control if actions are needed to investigate where the infection came from or to protect others from risk.

During my first four years I spent most of my time in the laboratory doing the first three bullet points.

Time goes on. I’ve been in the NHS for 17 years. Most of my time is spent at my desk in the on-call bathroom. Since 2010, most of my time has been spent either in Infection Prevention and Control undertaking the final bullet point or increasing my skills by gaining Fellowship of the Royal College of Pathologists to do bullet point four.

I still support the lab and, occasionally, get my lab coat on – but not as much as I’d like. It is, therefore, possible to be a clinical microbiologist and be anywhere on the spectrum. You can go as far as you’d like and do the type of work that makes you happy. It’s why being a clinical microbiologist is a great career!

Modernising Scientific Careers Framework

All opinions on this blog are my own