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Get a Free Frebreze Noticeable air freshener for FREE after mail in rebate.
1- First, purchase a new Febreze NOTICEables scented oil warmer.
2- Send in your NOTICEables receipt, UPC code and completed trade-up form HERE.
3- Get your a check for $3.50.
Please follow and like A Proverbs Wife:


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Maintaining Your Digital Storage
Over the years, we've accumulated a mountain of CDs, hard drives, devices, online accounts, and other mediums that store information. It's a good idea to periodically assess and dispose of unneeded storage media and information. Today, information may be split between physical items you have in your possession, and online accounts or cloud-based storage. (Does anyone else have a collection of floppy disks they've not been able to read for years?) This article will provide some details on how to manage your information and data, as well as how to safely dispose of pieces you no longer need.
Cleaning up Online Accounts and Cloud Storage
Clean your social media presence: It may have been years since you logged into an old social media platform that you no longer use. If that's the case, consider removing any personally identifiable information like address, date of birth, and other less sensitive details from the account. Furthermore, consider closing the account entirely if you don't think you'll have reason to use it anymore. The fewer places you have personal information stored online, the better!
Keep your social media presence clean: Minimize the amount of personal information on social media accounts you still use. In particular, minimize how visible your information is to unknown individuals. Most sites offer this as a privacy option in the settings for your account.
Close old shopping and rewards accounts: If you don't plan on shopping on a particular site, consider closing the account and removing any payment or personal information from the site. If you rarely shop on a web site, consider if it's necessary to maintain a user account. Most retail sites have a guest account option for temporary use and lessens the likelihood of your information being saved.
Cloud storage and files: Many of us use cloud storage services of some sort, whether it's to store photos or back up and storage of data files. Consider clearing out data and information from these storage accounts periodically that you will not need access to in the future.
Physical Storage – Digital and Paper
CDs, DVDs, Floppy Disks, and other plastic disk media: CDs and DVDs can be shredded in many household paper shredders (check to see if your shredder is rated for this). After validating if you need the information or not, consider this best and irreversible method for destroying the unneeded information and the medium. Floppy disks can be destroyed by splitting open the plastic casing, removing the soft disk itself, popping out the metal hub, and then feeding the soft disk without that metal center into a household paper shredder.
Hard disk drives, Solid State Drives, and USB flash drives: When you are looking to get rid of an old computer, you should properly clean your data off the device. Ensure you properly move photos, important records, and everything else you want to keep onto a newer device or a disk/thumb drive before you start clearing the data. Next, either physically destroy the drive or perform the proper process of overwriting by using a utility to permanently erase the data. For physical destruction of drives, either utilize a paid service to properly destroy the device, or follow this US-CERT guidance. There are many software utilities available to overwrite or permanently destroy data - one may be included with your operating system. US-CERT provides guidance on some utilities and ways to do this properly.
Smartphones, Tablets, Gaming Consoles, and other devices: Perform a "hard reset" which will bring the device back to factory settings and remove your data securely. Always ensure no accounts are permanently logged in on the device. You can consult the maker of the device when seeking guidance on how to locate this setting or utility for that particular make and model.
Disclaimer: These links are provided because they have information that may be useful. The Center for Internet Security (CIS) does not warrant the accuracy of any information contained in the links and neither endorses nor intends to promote the advertising of the resources listed herein. The opinions and statements contained in such resources are those of the author(s) and do not necessarily represent the opinions of CIS.

subset: commoncrawl


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As per latest update from Imugene Limited (ASX: IMU), the prominent City of Hope researchers have received a Grant of USD 564,173 from the US Department of Defense to study the company's Oncolytic Virotherapy (OV) CF33 in gastric cancer.
Marking a significant milestone, the grant received by the researchers is titled as "Discovery of Immune Biomarkers That Predict Response to a Novel Chimeric Immuno-Oncolytic Virus Encoding Anti-PD-L1 in Gastric Cancer Peritoneal Carcinomatosis."
Imugene is an Australian-headquartered clinical stage immuno-oncology firm that seeks to develop various novel and new immunotherapies to enhance the effectiveness of cancer treatments. The company has a strong product pipeline which includes CF33 and numerous immunotherapy B-cell vaccine candidates that intend to treat different forms of cancer in combination with standard of care medications and developing immunotherapies.
In July this year, the company notified about its proposal to license CF33 from City of Hope, which is subject to many customary conditions precedent and the approval by shareholders at the Extraordinary General Meeting, which is likely to be held on 18th of November, 2019.
Based near Los Angeles, City of Hope is an internationally recognised independent research and treatment center for diabetes, cancer and other deadly diseases.
Details of Grant
Imugene informed that the Grant is received by City of Hope researchers Yuman Fong, MD, Professor and Chair of the Department of Surgery and Yanghee Woo, MD, Associate Clinical Professor, Department of Surgery and Director, Gastroenterology Minimally Invasive Therapy Program, to expand the development of CF33.
The grant is centred on gastric cancer disease that affects the US veterans, military service members and their beneficiaries disproportionately, who have increased exposure to dangerous environmental risk factors, like Epstein-Barr viral infections, tobacco smoking, H. pylori and radiation.
Imugene's Role in Gastric Cancer Therapy
Imugene noted that gastric cancer can evolve into Peritoneal carcinomatosis (PC), which is fatal with no effective treatment. Also, more than 60 per cent of all gastric cancer patients across military families and the general population are at risk of developing the peritoneal disease as the most prevalent indication of recurrence or metastatic presentation.
The company mentioned that the progression of primary gastric cancer to peritoneal carcinomatosis is supported by the unique peritoneal tumour microenvironment, where metastatic peritoneal seeding needs maintenance of a highly immunosuppressive microenvironment and evasion of anti-tumour immunity.
As per City of Hope researchers, a combined approach using IMU's proposed license for CF33 armed with an anti-PD-L1 antibody (Ab) as immune modulator could convert the immunologically 'cold' environment of peritoneal carcinomatosis into a 'hot' environment, specifically kill cancer cells and enhance the overall effectiveness of gastric cancer therapy.
According to Ms Leslie Chong, MD and CEO of Imugene, both City of Hope and the company are committed to help enhance the quality and length of life for gastric cancer patients.
About City of Hope Researchers
Dr. Woo is a surgeon-scientist at City of Hope, who is internationally recognised and specially trained in gastric cancer and robotic surgery. Particularly, she holds an expertise in complex procedures like D2 lymphadenectomy for the treatment of locally advanced gastric cancer. She is one of the rare surgeons who treat pancreatic cancer and gastric cancer by making use of minimally invasive procedures.
She offers her patients entirely robotic and laparoscopic surgeries (for pancreas and stomach tumours) with optimal oncologic results while safeguarding the quality of life of cancer patients.
The world-renowned expert in pancreatic and liver cancer, Dr Fong is a pioneer both in the laboratory and the operating room. He is the Sangiacomo Family Chair in Surgical Oncology and the MD, Chair and Professor, Department of Surgery. He has developed a lot of new surgical instruments and techniques.
The CF33 oncolytic virus was also developed by Dr Fong in the lab at the City of Hope. Recently, he has been appointed by Imugene to lead its Oncolytic Virotherapy Scientific Advisory Board.
Imugene has congratulated Dr. Woo and Dr. Fong on receiving the sizable Grant from the US Department of Defense. The company feels honoured to work on the development of CF33 with the prolific and prestigious team of the City of Hope. Moreover, the company is planning to conduct CF33's Phase 1 clinical trials in 2020 to examine a Vaxinia construct and a CheckVacc construct of CF33.
Imugene is well positioned on the path to deliver on its clinical and commercial milestones. The company strongly believes that its immuno-oncology treatments will become foundation therapies for cancer.
Stock Performance: As on 24 October 2019, IMU is currently trading at $0.023 with a rise of 4.5 per cent. The stock has delivered a substantial return of 101 per cent in the last five years with a YTD return of 22.2%.
This website is a service of Kalkine Media Pty. Ltd. A.C.N. 629 651 672. The website has been prepared for informational purposes only and is not intended to be used as a complete source of information on any particular company. The above article is sponsored but NOT a solicitation or recommendation to buy, sell or hold the stock of the company (or companies) under discussion. We are neither licensed nor qualified to provide investment advice through this platform.
There is no investor left unperturbed with the ongoing trade conflicts between US-China and the devastating bushfire in Australia.
Are you wondering if the year 2020 might not have taken the right start? Dividend stocks could be the answer to that question.
As interest rates in Australia are already at record low levels, find out which dividend stocks are viewed as the most attractive investment opportunity in the current scenario in our report.


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Traders work at the New York Stock Exchange in New York, the United States, on Dec. 13, 2019. (Xinhua/Wang Ying)
Semiconductor stocks which led Monday's rise across the board became a drag on the market on Tuesday, while the genetically modified and environmental protection engineering sectors posted a strong performance. Tesla concept stocks and lithium battery shares basked in Tesla's rally. The US electric vehicle maker soared 9.77 percent to finish at $524.86 on Monday, setting a fresh record.
With market capitalization of $94.6 billion by Monday's market close, Tesla is now the most valuable car company in US history. An upward spiral in Tesla shares is expected in the foreseeable future, contributing to the NASDAQ rally that hit a new high on Monday.
In another major move to wind down its trade tensions with China, the US has ended its designation of China as a currency manipulator ahead of the phase one trade deal signing in Washington, DC.
A mild correction on the Chinese mainland market is not a big concern. That's especially the case considering the US�?reversal of its decision to label China as a currency manipulator, which is expected to defuse one of the biggest fears affecting investor sentiment.
Worth noting, however, is the Dow's failure to hit a fresh high on Monday, which hints at a slight lack of morale that could signal the start of a transitory correction in US stocks.


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The 10 Best Parody Movies
The Top Ten
One of the first but the funniest parody I have ever seen. It's got a really witty cracking script!
So funny 10/10 leslie nielson movies are always funny. Got off to a rough start but the awesome way it was played blew my shoes off
I started watching with a smile and at the end I was on floor dying laughing.. Extremely funny... Can't stop laughing even for a single minute.
Number 3? This is what every Parody Movie need to strive for, to be this good. This needs to be number 1.
It s number one because you have to be a real man to wear tights...
And because my full name is will scarlette o hara
This is the kind of parody that I enjoy watching the most. It's simply brilliant! If you don't like this movie, it means you don't have a sense of humor.
Brooks far most underrated work. "Unlike some other Robin Hoods, I can speak with an English accent"
Absolutely awesome. It was not only funny but it kept you entertained all the way to the end
After watching this movie I came to understand that you have to be very careful with science-fiction
Classic, and it makes me laugh my spaceballs off
WHY the HELL would you not like this movie? I love it, it was hilarious. This better rise to the top at ludicrous speed.
This movie is amazing has to be the best parody movie ever I think I love this more than Star Wars
Nobody feel bored watching this movie. Superhero Movie also good. I don't see Naked GUN. Surprising...
This movie is awesome its outrageously funny
Amazing its never bores me at all hope gonna be a new scary movie 5
It is the funniest parody ever. I will watch it any day, just bring it. It is the best. These people know how to make parodies
You just have to admit that this is by far one of the wittiest movies of all. The double-sided meanings make this more suitable for people who want a good laugh and not just dumb jokes like most other movies.
This is one of the best parody movies I have ever seen. Real humour, not nasty or vulgar. I laugh my ass off every time I see it, if you have not seen it, watch it right now!
Amazing movie, never get tired of it. Sorry for those who don't enjoy it (few words of German go long way)
this is by far the best parody/comedy movie of all time
I just love this movie. I think I have watched it 20 times or so. I'm a horror fan and also a comedy fan. Zombies mixed with humor is my cocktail of choice They should make a lot more movies like this one. In my opinion it should be nr.1 on the list. Cheers.
This is like one of the funniest movies ever, let alone the funniest spoof.
I love this movie, it is best movie, I want it to be number one on this list. Please
I watched this movie twice in one day I love it so much.
.. This is totally amazing.. Just laugh out loud.. Best Spoof ever.. And Scary movies are also good.. But Superhero Movie is the best..
Spiderman vs Dragonfly.. Laugh out loud.. He was bitten by a Dragonfly, you should watch this.. And the best Cast ever... SUPERB ACTING...! Nice Work
Start to End ==== laugh out loud
My favorite part is when they are eating and rick says he found a guy and when he tries to fly and jumps of the building and crashes with a statue.
Breaking news, Tom Cruise is dead. (Background couldn't fly laugh out loud) Great movie there is nothing bad about it also great acting for a parody just fantastic. Villain is The Hourglass haha
This movie was horrible. Unfunny and unoriginal, this merely copies other films and then lazily adds sophomoric bathroom humor.
It's sequels were so-so but this one really grasped what it was trying to do. Mike Myers at his best.
Best movie ever! Truly at the top most comedy level...
I can watch this over and over and still not get bored!
All I want are sharks with ' laser beams atached to their heads
Best movie ever made! The cast is Hilarious and just make this movie work. Then you add in Mel Brooks who is a Comedic Genius and you get a Masterpiece.
Why is this below Superhero Movie? That is a awful parody, this is literally one of the best comedies of all time.
Should be top 3! One of the funniest movies ever
It's so wrong its right
Honestly this movie is funny but I never much thought of it as a parody, It honestly seemed to take itself seriously. That being said its one of my all time favorite movies so I'm happy it made it pretty high up on the list.
What's this even a parody of? And it wasn't even that good. It made me fall asleep after 30 minutes into it. Though the fighting scenes were kind of cool.
It's inconceivable that this isn't higher on the list! It's one of the few movies that exists that makes me laugh every single time I watch it.
What's this even a parody of, I just thought it was a normal movie
The Contenders
One of the best made. Nice parodies of classics like " Cruel intentions " ( Mia Kirshner as hot as Sarah Michelle Gellar ), " Bring it on ", " Grease ", " Can't hardly wait " ( Jennifer Love Hewitt 's character Amanda Beckett replaced by look-alike Lacey Chabert as Amanda Becker ), " Sixteen candles ", " The Breakfast club " ( look in the beginning of the movie, it even says " John Hughes Highschool " ), " Porky's " and many other minor parodies of movies like " Clueless ", " Ferris Bueller's day off ", " The faculty "... This is a movie that you can watch over and over because you are always discovering minor details you have missed. This should be in the top 5 if you ask me.
When I typed in top ten parody movies on Google this is what made me type it is best parody movie ever
It is funny but all parody are funny don't be just in one side and insult the others
I suppose that we support them all
Love this teen parody movie!
This movie was really hilarious especially with that iconic bow and arrows (chicken) scene. Also, I laughed with the credit rolls of some ingredients.
Hot Shots is #12?!?! What has the world come to?!?!
By far the best parody movie out there. Only topped by part deux.
The Very Best Ever Shot!
Ono of the bests comedy films ever made
Scary Movie is notable as one of the worst movies of all time because of the sequels it spawned, but the first in the series is the one where the jokes are actually funny.
It was the final parody film that was actually funny, but it was also unfortunately responsible for inspiring a whole new (bad) standard for parody.
Best of all the "Scary Movie" series, but also stands alone as one of the funniest movie parodies of all time!
Leslie Nielson movies are always funny. And this one is the funniest.
One of the funniest movies I've ever seen
How is this not in the top 10? Leslie Nielson's funniest role right here.
Guaranteed LOFLs
Best spoof film ever they don't make them like that any more
It's a classic comedy and more than worth a watch! If you've already seen it, go watch it again!
"She turned me into a newt!... I got better"
Best movie EVER!
ABSOLUTELY THE FUNNEST MOVE I HAVE EVER SCENE. However, you must be somewhat knowledgeable about history to understand the humor!
A highly unrated musical treasure.
How much more black could this album cover get. And the answer... is none.
It goes to 11!
it s so funny. not really a parody of star trek but kind of star trek behind the curtain. sigourney is.. well watch it
What? This movie wasn't even in top 10 while it deserves being in top 3!
What a great movie. I was going to decide Thumb Wars until I saw this one. It's in the top 10 now.
A parody with a story, it is funny but it has a similar feeling of Star Trek itself.
Love this movie. I suggest you watch this is I for teens and adults but a good comedy flick. I love it and hope you guys can watch it
Does anyone who make these lists ever watch movie older than the year 2000? Spoof movies before then were far more creative with dialogue and sight gags.
This movie is just absolutely hilarious in a really really shake your head kind of way. Overall very enjoyable to watch and its always a go-to film for a silly night with friends.
Number one most best cop drama buddy comedy if only there was a dog
Here comes the Fuzz


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September's blog on Time Management is here!
Moving Evidence Forward
August's blog is by author Laura Grose, who discusses her motivations for writing this month's paper.
Moving Evidence Forward : Addressing the Barriers to Evidence Based Practice in Radiotherapy stemmed from a personal desire to implement changes into practice as a frontline Radiation Therapist (RT). While a practicing RT, I regularly found myself asking the question of why clinical decisions were not always based on the latest evidence but rather defaulted to RT clinical experience or cultural opinion. I felt there must be a way to instill evidence practices into clinical decision-making without disrupting the time-sensitive nature of treating patients.
One of the first issues encountered when dealing with evidence-based practice (EBP) is defining what, in fact, EBP is. The term has become ubiquitous in the medical world, everybody has heard of it, but the meaning seems to vary from practitioner to practitioner. For the purposes of this paper, evidence-based practice is defined as obtaining the best available evidence and incorporating it with patient values, local context, and professional clinical expertise (Guyatt, Rennie, Meade, & Cook, 2015; Heneghan, 2008).
An additional issue with EBP is incorporating it into standard practice without placing undue difficulty on practitioners. If an RT is expected to embrace and use EBP as a crucial part of practice to reach good decisions, how is it feasible with the demands of clinical environments focused on service delivery?
This paper has two parts. The first is an overview of how other professions, such as nurses, pharmacists, and physicians, keep current and integrate EBP into their practices. The second is an investigation into how RTs themselves view evidence-based practice and whether they would use tools to promote such practice, if available.
In the end, it is clear that there are technological point-of-care (POC) tools that can potentially support RTs in implementing EBP. As well, RTs appear overwhelmingly in favour of using evidence-based practice and would incorporate POC tools if they were relevant and made available.
This paper intended to inspire ideas and launch a discussion about evidence practices in radiotherapy and see how we can move forward with new methods and initiatives in order to be accountable for delivering optimal patient care. I am also hoping to highlight the importance of research and the need to connect it to radiation therapists' increasingly demanding daily practice.
Guyatt, G., Rennie, D, Meade, M., & Cook, D. (Eds.). (2015). User's guide to the medical literature: A manual for evidence-based practice (3rd ed.). United States: McGraw Hill Education
Heneghan, C. (2008). Developing evidence-based medicine in everyday practice. The Foundation Years, 4(5), 207-209. doi: 10.1016/j.mpfou.2008.06.004
Thoughts on Scopes of Practice
July's blog is by Mark Given, the Director of Professional Practice for the Canadian Association of Medical Radiation Technologists.
I had the opportunity to read the Sale et al "National Survey on the Practice of Radiation Therapists in Australia" paper and it provided me yet another opportunity to reflect on MRT or radiographer practice and what roles practitioners, associations and regulatory bodies play in advancing our scopes of practice.
The paper effectively highlights the difficulties associated with defining the ever moving target of what practice is and how our professions evolve. The ever changing technology, how work is segmented within departments, the service offered within individual facilities (or within a facility) and how staff are utilized are all key elements of how our practice is defined.
The paper highlights the core roles, non-core roles and even advanced competencies for practitioners in radiation therapy and gives insight on how the radiation therapist's role can be defined in much greater detail than any one sentence or paragraph definition could ever do.
As stated within the paper "Ultimately the better utilization of the skills of RTs should contribute to improved provision of treatment in cancer patients." For me, this statement is the take home message for every practice decision that practitioners in our field must consider. Often we make the mistake of defining our professions by the technologies that we work with instead of by the professional skills and attributes that define us as professionals. If every practitioner puts quality, safety, patient experience and efficiency as drivers for change, then our professions have the ability to expand our current scope of practice and move beyond our regular confines into advanced practice roles.
As practitioners, I strongly believe it is within our control to take our professions to where we want them to be. Identifying patient and system needs is the critical element to the successful implementation of innovative changes with our current practice models. As identified in the paper, the need for local champions is imperative for the successful integration of new care models. Equally important is the education required to take on these practice changes along with the data and evaluations that support these innovations upon implementation. It is also the practitioner's responsibility to share their experiences through networking or though academic or scholarly contributions.
Associations need to be the voice of the profession. In Canada, the Canadian Association of Medical Radiation Technologists (CAMRT), like the Australian Institute of Radiographers (AIR) and many others internationally, supports the profession by defining the profession, providing national competency profiles, supports the development of advance practice roles and advocates for the advancement of the profession.
The role of regulatory bodies is primarily to ensure the safety of the public and to ensure the safe and effective practice of their members. In Canada we currently have 6 regulatory bodies that define the scope of practice within their respective province and we have 4 provinces that are not currently regulated. A few of the goals of the Alliance of Medical Radiation Technologists Regulators of Canada (AMRTRC) are to work collaboratively to encourage and promote standardized regulatory policies and procedures, and to develop, promote and evaluate common standards between jurisdictions.
It is truly difficult to sum up a topic such as this in a 500 word blog. But perhaps more importantly this can open up a broader conversation with the international community…..
What do you think is the role of practitioners in advancing their scope of practice?
How do we develop the educational programs required to take on additional responsibilities?
How do we as professionals evaluate and communicate our achievements?
What products and services do practitioners required from their associations to advance their respective scopes of practice?
How do we effectively engage regulatory bodies to allow for expansion of our scopes of practice?
A MRJC author reflects!
June's blog is by our May author Jill Bleiker. Jill discusses her research journey and what it's like to have your paper discussed at MRJC!
I thought I was pleased enough to have had my article, the snappily titled 'Compassionate care in radiography recruitment, education and training: A post-Francis Report review of the current literature and patient perspectives' accepted for publication in Radiography but when I received an email from the Editor-in-Chief telling me that it had been selected for discussion in the May 2016 online journal club for medical imaging professionals, I realised there was more emotion to come. At first, surprise, pride, excitement (particularly as I am a PhD student of very mature years on a quest for data with which to answer my research questions) but not long after, the cold finger of fear poked me; 'What if they call it a load of tosh?' 'What kind of fool would write this pretentious rubbish?' Oh yes, I know how to auto-undermine my own self confidence…
I know that many of my academic colleagues are familiar with 'imposter syndrome': that feeling that sooner or later, (and more probably sooner) you are going to get found out – someone is going to say "This person is a fraud – they have no business here; they know nothing about this subject!" Followed swiftly by shameful expulsion from whichever workplace or institution the unhappy fraudster was attempting to infiltrate. Although I passed my DCR(R) over 35 years ago, I still remember as a newly qualified radiographer that same feeling, standing in the viewing room amongst a group of so-called colleagues, all of whom were more senior, learned and experienced than me – I wonder if today's graduates suffer the same doubts and insecurities, or whether the high quality training and education they receive prepares them better, fostering confidence and a more questioning attitude for professional practice. Ironically, the process of reflection, a key element in radiographers' CPD may actually serve to foster imposter syndrome rather than ameliorate for it.
So, placing my fears firmly to one side and allowing gratitude for this golden opportunity to collect data for my PhD to wash over me instead, I submitted some research questions to the editorial team for creation of themes for the upcoming discussion. I was keen that contributors be aware that I had a research interest in what they had to say, but also wanted them to be reassured that anything tweeted would be fully anonymised so that no-one could be identified from their comments; I'd like to reiterate that promise here and now. Normally blogs are written in order to inform the Twitter discussion to follow, but as I didn't want any data contaminated by my beliefs, preconceptions and ideas generated during my preliminary literature searches, I wrote this blog retrospectively rather than prospectively, and during the whole 15 hours on Twitter, exercised more self-restraint than I thought I possessed and stayed out of the conversations.
There were some fascinating comments and very thoughtful insights and it gave me goosebumps to see the care, integrity, commitment – even soul-searching that flowed through the forum. To me, this is now a demonstrable part of what radiographers are being, as well as doing every day.
Data analysis is shortly to begin under the guidance of my qualitative methodology supervisor, and I intend to share the results and any conclusions in due course in order that others who are interested might use the information to inform their CPD or further research. For the time being, I would like to record my gratitude to the forum convenors and facilitators, to #MedRadJClub and to everyone who contributed to the discussion.
Compassionate Care – I am more than the sum of my body parts
This month's blog is by Prof Sarah Lewis, Associate Professor in the Faculty of Health Sciences at the University of Sydney.
As an MRS educator, I constantly tell my students "do not refer to patients by their body part". There is nothing less compassionate about referring a frail old lady with a suspected fractured neck of femur as "a NOF". Nothing more uncaring than saying that your next radiation therapy patient is a "brain". In truth, many patients already feel this is what they are somehow reduced to; a tumour, a bone, a liver, a brain. How do I know this? Because I was "a breast".
It took me a while to find my patient voice and I was adamant I would not be a poster girl for mothers with cancer, nor would I be a token survivor. However, lately I have found that people, both patients and MRS practitioners, have sought some comfort or education in my story and hence again now I speak from a patient's perspective (although my academic hat is never far away).
Having had extensive medical imaging, chemotherapy and radiation therapy, I know I experienced good care. Certainly, the drugs, surgery and radiation I received have given me a high chance of growing old cancer free. But the best care I received was when I was treated as a whole person, when my care was not defined by my dodgy breast but rather as a 38 year old mother of two boys that needed a dose of chemotherapy or a CT scan for cancer staging. When my whole body and mind was treated together and I was treated as more than the sum of my body parts, I felt secure and calm about my diagnosis and treatment.
The best example I can give of this was the day I met the medical oncology registrar – it was the day of my first chemotherapy session. She was a young doctor who was undoubtedly bright and overworked, who proceeded to read my file from the beginning not really knowing why I was there that day. It was very clear that she had no idea who I was and the first words she said to me were "have you had your breast removed?" My body parts were more important to her than introducing herself or asking how I was.
In truth, that particular day I was terrified of the drugs that would run through my veins and the inescapable nausea and vomiting that was coming. The thought of the cannula insertion terrified me and I was worried I would cry. I did cry that day, but not from any physical pain but because the most stressful day of my 12 months of treatment was reduced to my body part. I was, and am, so much more than this.
Compassionate care is about treating the whole patient with dignity, not as an organ or disease. Medical radiation practitioners must remember to focus on the patient, their names, their faces and their challenges. Take the time to look into your patients eyes and believe that each interaction you have is valuable to them and shapes their perception of great care.
Inter-Professional Learning – Closer than You Think
This month's blog is by Janice St. John-Matthews, Allied Health Professions Associate Head of Department (CPD and Workforce Learning) at the University of the West of England, Bristol.
The words "inter-professional learning" will have a different meaning to different radiography groups. For undergraduate learners it is an opportunity to explore the role of each of the healthcare professions and the importance of working collegiately. For advanced radiographers this can mean extending skills in to areas of other professional groups i.e. radiographer- led discharge; review-radiographer. However sometimes inter-professional opportunities are closer than you think.
It wasn't until I co-authored a paper with radiotherapy colleagues that the question of radiographer inter-professional working arose. While describing how a patient pathway had been improved the authors opted to use the word intra-professional. After all if someone works with radiation, cares for patients and fulfils national registration requirements surely they are from the same professional group- irrespective of whether the pre-fix is diagnostic or therapeutic? However the peer-reviewers disagreed, requesting our word choice be changed to inter-professional working.
At the time I was confused. In the UK diagnostic and therapeutic radiographers share the same standards of proficiency document (HCPC, 2013). It makes sense. There is overlap with the professional standards and the parts that differ- often techniques- are given their own subsections in the document. I studied in a Higher Education Institute that trains both professions and also teach in a similar arrangement whereby some modules are shared and others are separated. However reflecting on the request I realised that for my career outside of academia I have not worked near a radiotherapy unit or alongside my radiotherapy colleagues.
There is much learning we can take from our radiographer counterparts. I found working with radiotherapy and diagnostic radiographers for the aforementioned paper enhanced my patient care skills, made me reconsider standards of professionalism and best practice. It did of course help that the radiotherapy radiographer leading the work had completed a postgraduate certificate in CT scanning. They had challenged themselves to learn to scan to the same level as their fellow diagnostic radiographers. Long gone are the days where the radiotherapy team turn up on a Friday afternoon to the diagnostic department, flat table-top under their arm. Moreover gone also are the days where the radiotherapy radiographer could position their patient in the CT suite but could not scan. (I was never sure how that worked for a profession who uses much higher dose levels).
This isn't about radiotherapy radiographers taking over the wider radiography world as imaging becomes the norm in their departments. During the 2015 UK Radiological Congress (UKRC), I sat in on a dedicated radiotherapy session. Yes presenting was a radiotherapy radiographer who had completed a MSc. in Ultrasound so as to enhance their local prostate radiotherapy service. However there was also a presentation from a diagnostic radiographer who had completed intra-operative radiotherapy competencies so breast cancer patients didn't have to drive long-distances for treatment. These two presenters had had to learn new skills from radiography colleagues who shared a common title but who had distinct professional identities.
As our professions evolve there are still many more inter-professional learning opportunities. As a cross-sectional radiographer I am keen to see how widespread MRI-guided Linear Accelerators and MRI guided radiotherapy becomes. This will have implications on the training needed by the radiotherapy workforce to operate this equipment safely. Likewise I am eager to see what the diagnostic radiography community can learn with the radiotherapy community in the UK recently achieving independent prescribing rights.
In the interim as this blog coincides with the 11TH Annual Scientific Meeting of Medical Imaging and Radiation Therapy (ASMMIRT) 2016 I challenge those attending to sit in on a session from the "other" radiography professional groups. And for those who can't make it to sunny Brisbane there is always Liverpool here in the UK in June where for the first time UK Radiation Oncology Conference (UKRO) and UK Radiological Conference (UKRC) will be running alongside each other. If you are lucky you may even meet a truly inter-professional "dual-trained" radiographer. Now is that inter-professional or intra-professional working? Or are we stepping back to the future?
"The Student" becomes "The Therapist"
This month's blog comes from Carina Feuz, who is a Clinical Coordinator at the Princess Margaret Cancer Center in Toronto, Canada. Enjoy Carina's riff on Naylor et al's paper on the transition from student to radiographer/medical radiation technologist!
As a clinical coordinator for radiation therapy, I have attended many convocation ceremonies and have enjoyed watching the graduates celebrate their achievements. Gone are the anxieties of competencies and evaluations which are now replaced with nervous and excited chatter about pending certification exam results and job interviews. Now, let's fast forward to the first day of a new job. This is the day when the former student turns to a patient and for the first time says, "Hi, My name is Carina and I am a Radiation Therapist." Years of school, hours of study and multiple clinical rotations has led to this momentous occasion. It is both an amazing and truly terrifying moment as these new graduates come to realize that they are no longer "the student" (insert air quotations here) and are now "the therapist" with all the rights, privileges and responsibilities that come with that title. Gone are the carefree days of letting "the therapists" take on the challenging and difficult situations. If you didn't know what to do, just ask "the therapist." For some new practitioners, the reality of being responsible for the care and treatment of a patient can be sometimes overwhelming, especially if a long period of time has elapsed since their time as a student and their first day of employment.
I split my time between clinical education and working directly with patients on the treatment unit and I often get to work with new practitioners. I see their eagerness to prove themselves to staff but also the moments of doubt when they realize they are "the therapist" and they are expected to make decisions on their own and be autonomous practitioners. They are sometimes afraid to make the judgment call when only a few weeks or months ago, they would have not hesitated to make the same decision. The game has now changed; the rules and expectations are different. It takes time for new practitioners to establish their professional identity and to acclimatize into a new environment and role. Throw in the additional responsibility of teaching students who are looking to staff for guidance and there are even more expectations to live up to as "the therapist."
So what can be done to help new practitioners integrate into their new career as a health care professional? Like students entering the clinical environment, an orientation period is very important. When I first came on staff as a "new graduate," I walked into the cancer centre and I was asked, "Do you want to work on the treatment unit or go to simulation?" There was no orientation period and my ID badge hadn't even cooled yet before I was introducing myself to my first patient with an eager wide-eyed student watching my every move. (I should say the time between my time as a student and my first day of work was about 3 weeks). Needless to say, I was double-checking everything (aka "new grad-itis"). What I did have was a great team of senior therapists who acted as my mentors for those first few months as being "a therapist."
Mentorship and preceptorship strategies are great ways to support new practitioners. Not only are they available to provide support regarding the technical aspect of the job but to also assist new practitioners acclimatizing to the professional world of health care. I often hear from the "new graduates" that they were unaware of all the tasks that went on behind-the-scenes which they did not have to deal with as "a student." Who to call? When? For what reason? Is it better to call or e-mail? Are rounds really necessary? Where is the nearest Starbucks/Tim Hortons? New practitioners should be partnered with senior staff either in a formal preceptorship or mentorship role. Senior staff are excellent resources, as they are aware of the typical challenges and have had the opportunity to learn from their own (dare I say) mistakes and can pass these lesson's onto new practitioners. Graduated responsibility is another great strategy. Mentors or preceptors work alongside new practitioners and over time gradually reduce the amount of direct supervision. This allows new practitioners to build their confidence in their new professional role while knowing there are supports available to them, if needed.
One final and very important element to emphasize when helping the new practitioner to transition into their new role is providing feedback, in particular during the orientation period. Constructive feedback should be relevant and given in a timely fashion so that if needed, strategies can be put into place before "going live." Feedback should also not be limited to just the new practitioner. Self-evaluation is important for new practitioners so that they can communicate their own learning and training needs to the clinical educator during orientation. This ensures that the new practitioner is comfortable "going live" as a confident contributing member of the health care team.
Academic Output – Where does radiography stand?
This month's blog on the research output of radiographers is by Peter Hogg, Professor of Radiography and Research Dean & Director of the Centre for Health Sciences research at Salford University and Visiting Researcher at the Karolinska Institute.
Radiographers, nuclear medicine technologists and radiation therapists have a poor tradition of doing research. As they moved to graduate (BSc) and high graduate (MSc) education it was anticipated this would change, but it did not have a tremendous impact. Many are now gaining PhD qualifications, but again this does not appear to be having the anticipated impact. One explanation could be this – many European educators are required to have a PhD, but they are not encouraged or supported to conduct research after getting one. Is PhD seen as an end, rather than the beginning?
To advance practice and for radiography / nuclear medicine technology / radiation therapy to retain their professional status research is essential. Our poor tradition of research needs to change urgently.
Ernest, Mark and I are keen researchers. Knowing that collaboration is essential to be a successful researcher we decided to attempt to identify productive researchers and productive groups of researchers in our professional area as such a list would give us an indication of who is doing what and also who potential collaborators might be. Given the time taken to acquire and analyse the data we decided to translate our data into a paper (A Review of Individual and Institutional Publication Productivity in Medical Radiation Science). Our method has many flaws, but it does represent a logical advancement on Bev's[1] and Geoff's[2] initial work, as it takes into account a wider range of information. Flaws include lack of ability to identify all researchers in the world, only journal papers within Scopus / Scival were available for analysis, only data provided by Scopus / Scival on a specific date and time could be used and, of course, the metrics provided in our paper do not necessarily give insight into the quality of each journal article. I suspect quality would best be determined by reading the article against criteria, in a fashion similar to the UK Research Excellence Framework[3]. Further work still needs doing. Anyway…
Our paper paints a fairly poor picture of research conducted in our profession. However it does identify groups of people where productivity is high and it also identifies individuals who are highly productive too.
Getting a research unit off the ground isn't easy. As a teacher I have developed a number of master's programmes; from development to full implementations can take 2-3 years. It's not easy. In early 2009 I established a research unit for radiography, 7 years on it is still being established. I suspect it could take ten years or more to fully establish a research unit. Largely it comes down to environmental factors, including resource (financial, physical and human). One important reason is worth highlighting. It relates to academic staff development. Part time it can take 5-6 years to complete a PhD. On PhD attainment they would generally be regarded as a novice and highly inexperienced researcher. The next stage in their development typically involves 5 years of training / development in order to become a competent researcher. UK universities normally require 5 years post doc for the individual to become a competent researcher. Within our profession this post doc development opportunity is pretty much devoid. This brings me back to a point in the first paragraph of this blog, "Many are now gaining PhD qualifications, but again…" Training, whether BSc, MSc or PhD, in isolation of other significant contextual factors is simply not adequate for solving our problem. Considerably more thought and resource needs to be devoted to solving the problem of facilitating / enabling: individuals; university / hospital radiography departments; and our professional bodies – in order to realise our research ambitions.
[1] Snaith, B. A. (2013). An evaluation of author productivity in international radiography journals 2004-2011. J Med Radiat Sci 60(3), 93–99.
[2] McKellar, C., & Currie, G. (2015). Publication productivity in nuclear medicine. J Nucl Med Technol 43(2), 122–128
Emotional Intelligence – A radiography perspective
Stuart Mackay has been teaching and researching in radiography for over 25 years and since 2007 has had a special interest in emotional intelligence and its application to radiography. He has authored several papers on the subject and teaches it to radiotherapy and diagnostic radiography students on their degrees at the University of Liverpool.
As we complete 2015 it occurred to me that Emotional Intelligence (EI) research has been going for 25 years now and the concept is quite well described in the literature. There are a number of validated tools for its measurement although each have their weaknesses. But, we still have long way to go to understand it and use it effectively for the benefit of our profession and our patients. The paper from JMRS which is the topic of this month's chat is from a wider longitudinal study where we are following a cohort of radiography students from the start of their degree programmes through to 6 months after qualifying to see if their emotional intelligence scores, as determined by the Trait EI questionnaire of Petrides, change over time. We know from surveys of UK and Australian radiographer populations that radiographers in general score higher in their EI than population norms. The data in this paper demonstrated that students at the start of their training programmes were significantly different than qualified radiographers scoring much lower an almost all the EI factors of well-being, self-control, emotionality and sociability. Therefore, we are tracking the students' scores to observe any change that might occur on their way to qualification. We are currently analysing years 2 and 3 with more presentations and publications to follow this year.
Some really interesting and challenging questions arise from his work…
- The trait EI model states that there is unlikely to be a dramatic change in an individual's EI score over their lifespan. Yet we have seen that the EI score for the baseline students group was statistically significantly lower than that for the qualified staff groups (in UK and Australia) that we surveyed in 2012. What do you think we might find as we track the scores of radiography students through to qualification?
- Why might the students in our group not have demonstrated any significant difference in EI score with the general population norms?
- We have used the published and well validated, self-report, short form of the Trait Emotional Intelligence Questionnaire. Which others might we have used?
- Can you describe examples of radiographer emotionally intelligent behaviour with patients and staff? Can you articulate what might they be thinking or feeling at the time?
- Might EI training be a way of developing resilience to try and reduce the risk of the stress and burnout described by Poulsen et al. in their blog and JMRS article A cross-sectional study of stressors and coping mechanisms used by radiation therapists and oncology nurses: Resilience in Cancer Care Study JMRS, 2014.
There are also some key questions for the profession and NHS.
- Can we use EI tests for the selection and recruitment of student radiographers? This might help us to select those students who might have high emotional intelligence and be better able to recognise and respond to the needs of patients and be more resilient to the pressures of working in the NHS?
- Dark side of EI. Is having a high EI always a good thing? A high EI can be used to manipulate others to achieve a particular outcome which might not be co-incident with the values of the NHS. Discuss!
Chocolate and the radiography profession – future research requirements
This month's blog is authored by Bev Snaith, the Lead Consultant Radiographer at Mid Yorkshire Hospitals, UK. She was one of the first consultant radiographers and still retains a full-time clinical role blending radiographic reporting, ultrasound, leadership, education and research.
Well time for 2 confessions as I write this blog to supplement the December #MedRadJclub discussions inspired by a covert observational study of chocolate consumption on a hospital ward (BMJ 2013;347:f7198).
- This is my first blog
- This is not my first discussion of the merits of different chocolate products
As a confirmed 'sweet tooth' radiographer, the subject of this month's article interests me no end, not just because of the topic but because it does something very difficult – successfully makes research accessible and relevant.
But this got me thinking, how would we carry out a similar study in radiography? First question (because you always start with a research question) was obviously when did we last get chocolate? But then more importantly is there variation or similarity between the diagnostic and therapeutic radiography branches? Having shared a house with 2 therapy students whilst training there appeared to be a significant variation in the availability of chocolate in our daily clinical placement (statistical significance not tested). Years later I now reflect on that, not just as a potential confounder in discussion of a research study, but more importantly why?
This most likely illustrates the relationship we build with patients, not saying that radiation therapists are nicer but rather the brief encounter in a diagnostic department contrasts starkly with a bond developed over many visits to a therapy centre. Did this subtle but vast difference drive some of us down our chosen career paths? Importantly, as has been touched on many times during the monthly journal club discussions during the year, how does this patient relationship impact on our decision making and choices? As an ED consultant friend once stated "I'm a 20minute doctor" – that's all the time she had for patient interaction during their stay with her (4 hour Emergency department window in the UK). That focused her to consider all diagnostic and therapeutic options but not build a relationship with the patient, as opposed to the ward where doctors and nurses are a continual part of the day (and obviously the recipients of many boxes of chocolates).
But back to the planning of our research study, what would we want to know? Well obviously we would be more interested in half life than survival time and as we need to increase our evidence base on outcomes, what was the effect? Does eating chocolate improve quality, effectiveness or productivity of radiographers? Do we become happier? Indeed as the latter has already been the subject of a previous RCT and therefore questions of research validity have already been proposed this is ripe for a radiography study.
Importantly, when undertaking a brief literature review on the subjects radiographer and chocolate I was surprised to see how much research is already being conducted by radiographers on the effects of chocolate, particularly in the neuroimaging field. Research has shown different patterns of response in the brain when eating chocolate because we are hungry or just gorging, and a follow up. That made me think of when I last fed a patient chocolate in clinical practice, anyone else remember handing out a bar of dairy milk or a Mars bar during an oral cholecystogram?
But for the budding researchers, chocolate consumption has been found to be a coping mechanism in combatting stress – I am not alone!
So, in the (hopefully) chocolate laden month of December consider the impact the next mouthful has, not just on your waistline, but importantly how does it affect your interaction with colleagues and patients. I look forward to chocolate themed research proposals in the New Year, I'm sure there will be a number of volunteers as international collaborators.
Merry Christmas to all sMaRTieS
(for those of you wondering about the smartie relevance, when teaching in NZ I struggled to get MRT out effectively, so all the students became the hard shelled sweet)
Dose optimisation: November (World Radiography Day)
This month's guest blog is by Dr Andrew England, Senior Lecturer in Radiography at the University of Salford. Andrew completed his PhD in 2013 and has co-authored a series of journal articles on the theme of dose optimisation within radiography1-4.
When Roentgen first discovered his new kind of ray, he could not have imagined what innovations it would lead to. However, initially it did come with a high price as the effects of ionising radiation on biological systems was severe and of a lasting nature. Protection against its effects is now well established largely due to the efforts, and in many cases, the lives of those early pioneers. Today, diagnostic radiology plays a dominant and ever increasing role in modern medicine. It is up to the current and future radiographers and radiologic technologists to learn from the past, adhere to current radiation safety standards and find new ways to ensure that examinations are low dose.
One current theme of radiation safety is the concept of dose optimisation. This is the process whereby the radiation dose for a given examination is carefully considered alongside the likely resultant image quality. The International Commission on Radiological Protection (ICRP) defines optimisation as the 'process to keep the magnitude of individual doses as low as reasonably achievable'5. Within the United Kingdom the process is enshrined in law as part of the Ionising Radiation Medical Exposure Regulations (IRMER)6 and is often given the acronym ALARP with achievable being replaced with practicable.
Optimisation is not restricted to digital radiography (DR) but also encompasses film-screen, fluoroscopy and computed tomography (CT) systems. In order to adopt this concept within clinical practice practitioners need to have an awareness of image quality, radiation and dose and their relationships and influencing factors. Within this process frequent discussions arise regarding image quality, acceptable levels and its overall assessment.
Challenges within radiography have resulted from a lack of objective or fully validated methods for assessing clinical image quality. Decisions regarding the acceptance or rejection of a radiographic image are commonly based on the individual perception of the responsible healthcare professional (radiographer or radiologic technologist). Further problems arise when practitioners are required to consider whether an image of an acceptable diagnostic quality whilst considering the intended purpose of the examination. Within the field of optimisation, such decisions are a fundamental requirement since they dictate the minimum level of image quality necessary for an examination. Once this is known then the next step is for the practitioner to consider the acquisition factors available and how they can be used to minimise the radiation dose from the examination.
It is likely that there would be numerous acquisition factor combinations which could deliver an acceptable image but with significant variations in patient dose. For a practitioner to have full control of the radiation aspect of the examination necessitates that they have a comprehensive knowledge of the performance and characteristics of the imaging system (DR, CT or fluoroscopy). Within this the practitioner must have a thorough understanding of the response of the imaging system to changes in acquisition parameters (e.g. kVp, mAs, SID, additional filtration) and also a knowledge of dosimetry. Dosimetric considerations must factor in the area under investigation together the gender and age of the patient.
Predicting the response of the imaging system to changes in acquisition parameters, for film-screen systems, was more simple. Experiences with film-screen systems spanned across many decades and there is a well-known response of X-ray film to ionising radiation. Film-screen systems have a limited range of exposures which would allow the production of an acceptable quality image and thus the practice of ALARP was easier. For digital systems, including CT and fluoroscopy, the response to over- or under-exposure is very different. For under-exposure, instead of an image which is too white (film-screen), there would be an increase in quantum noise (the image would look grainy). Over-exposure is more challenging to detect and often there are no perceptual changes to an image, unless there is extreme over-exposure. Often such instances can only be identified by relying on manufacturer exposure indices. It must be said that the interpretation of these values varies significantly between manufactures and their utility has been subject to much debate7.
The introduction of digital radiography has come at a rapid rate. Many departments for decades relied on film-screen systems and within a few days had become totally digital. This rapid change has left many practitioners unsure of optimum acquisition parameters and unsure of the response of each system to changes in such parameters. Luckily all is not bad, radiography curricula have adapted accordingly and we are now perhaps entering a golden age of optimisation. Evidence for this is within the contents page of many radiographic journals which demonstrate a rise in the number of studies investigating dose optimisation. Optimisation studies are frequently presented at national and international conferences and their a specific funding calls for research in this area. Optimisation research also now transcends international boundaries and is high on the agenda of many international organisations and professional/regulatory bodies. Further evidence of its interest and importance can be taken from it being selected as theme within this Journal Club. The challenge is still to encourage research in this area but develop its quality and impact. Ultimately we need to move towards a goal of how radiographic cultures can be developed in order to incorporate key optimisation findings within routine clinical practice.
- Davey, E., England, A. AP versus PA positioning in lumbar spine computed radiography: Image quality and individual organ doses. Radiography 2015;21(2):188-196.
- Harding, L., Manning-Stanley, AS., Evans, P., Taylor, EM., Charnock, P., England A. Optimum patient orientation for pelvic and hip radiography: A randomized trial. Radiography 2014;20(1):22-32.
- Mraity, H., England, A., Hogg, P. Developing and validating a psychometric scale for image quality assessment. Radiography 2014;20(4):306-311.
- Mraity, H., England, A., Akhtar, I., Aslam, A., De Lange, R., Momoniat, H., Nicoulaz, S., Ribeiro, A., Mazhir, S., Hogg, P. Development and validation of a psychometric scale for assessing PA chest image quality: A pilot study. Radiography 2014;20(4):312-317.
- International Commission on Radiological Protection. Recommendations. Publication 60. Annals of the ICRP 21. Oxford: Pergamun Press, 1990.
- Health and Safety Legislation. Statutory Instrument 2000 No. 1059. The Ionising Radiation (Medical Exposure) Regulations 2000. http://www.legislation.gov.uk/uksi/2000/1059/contents/made (last accessed 4th November 2015).
- Warren-Forward, H., Arthur, L., Hobson, L., Skinner, R., Watts, A., Clapham, K., Lou, D, Cook, A. An assessment of exposure indices in computed radiography for the posterior-anterior chest and the lateral lumbar spine. Br J Radiol 2014;80(949):26-31.
Radiographer decision making: October
Dr Ruth Strudwick is an Associate Professor is Diagnostic Radiography at University Campus Suffolk (UCS), she completed her Professional Doctorate in 2011 and her thesis was entitled 'An ethnographic study of the culture in a Diagnostic Imaging Department'1.
Although other health care professionals produce and use images, the radiographic image is the product of the radiographer's interaction with the patient. This is the purpose of the imaging procedure2. The image encapsulates not just the science of producing an image from X-rays but is also a record of the interaction that occurs.
The image is used to aid in diagnosis and treatment of the patient3. Radiographic images are, however, context dependent and when viewing the image the observer has no awareness of the state of the patient at the time of image acquisition4.
For the diagnostic radiographer and the mammographer 5 there is a conflict between the 'process' (the patient experience) and the 'product' (the resultant image). Radiographers take responsibility for and value their resultant radiographs6. However, they are caring professionals, and although their interaction with the patient is 'task focussed' – that task being the production of the image, they should also provide good quality care, ensuring the examination is not too painful or uncomfortable. The radiographer makes decisions throughout the examination using direct observation of the patient, speaking to and interacting with the patient and listening to cues from the patient. They constantly evaluate the decisions they make in order to produce a good quality image, although sometimes this may result in an image that is 'good enough' rather than 'good'.
Reeves and Decker2 argue that it is the radiographic image and not the patient at the centre of radiographic practice. The production of a radiographic image could be seen as the long-term goal of the examination and humanistic interaction could be seen as the short-term goal needed to acquire the image2, 7.
It is easier to measure the quality of the radiographic image than the quality of the interpersonal interaction between radiographer and patient. However, there is little success in producing an excellent diagnostic radiographic image if the patient is very upset or in a lot of pain during the examination. Conversely there is no point in keeping the patient happy and pain free if the radiographer does not position the patient correctly and does not produce a good quality image for diagnosis. There is the need to balance these two important aspects. However, technical competence may be prioritised over patient care8.
Radiographers display a strong ownership of their images. This is like a parental or artistic relationship; 'my baby' – 'my image', I made it and created it. Consequently, criticism of the image is taken personally, as a criticism of the radiographer themselves and a reflection on them as a professional. The image does not provide information about how the patient was at the time of the examination; it is not possible to tell if this was the best quality radiographic image that could be produced. This is similar in mammography where it is not evident from the image how the patient reacted to the use of compression and how that affected the resultant image. The authors of the given article suggest that some mammographers placed patient pain as a higher concern than image quality and vice versa5.
Radiographers are responsible for making a judgement about the diagnostic usefulness of their images. This is subjective and professionals differ in their quality assessment of images. Radiographers tend to decide 'is this image 'good' or 'good enough'?'9
It will always be a conflict in the radiographer's psyche where they have to balance producing a diagnostic image and being a caring professional.
1. Strudwick R M (2011) An ethnographic study of the culture in a Diagnostic Imaging Department (DID). DProf thesis, unpublished, University of Salford
2. Reeves P J and Decker S (2012) Diagnostic radiography: A study in distancing. Radiography, 18(2) p78-83
3. Reeves P J (1999) Models of care for diagnostic radiography and their use in the education of undergraduate and postgraduate students. University of Wales, Bangor.
4. Strudwick R M (2014) The Radiographic Image: A Cultural Artefact? Radiography, Vol 20. Issue 2, May 2014, p143-147
5. Nightingale J M, Murphy F J, Robinson L, Newton-Hughes A, and Hogg P (2015) Breast compression – An exploration of problem solving and decision-making in mammography. Radiography (2015) 21 (4), p364-369.
6. Fridell K, Aspelin P, Edgren L, Lindskold L, and Lundberg N (2009) PACS influence the radiographer's work. Radiography (2009) 15, p121-133.
7. Adler A M and Carlton R R (Eds.) (2007) Introduction to radiologic sciences and patient care. Elsevier, London.
8. Whiting C (2009) Promoting professionalism. Synergy, September 2009, p4-7.
9. Ween B, Kristoffersen D T, Hamilton G A, and Olsen D R (2005) Image quality preferences among radiographers and radiologists. A conjoint analysis. Radiography (2005) 11, p191-197.
Role extension in low resource settings: September
This month's blog role extension and expansion by radiographers in low resource settings is by Cynthia Cowling; Senior Lecturer at Monash University, adjunct Associate Professor at Central Queensland University and immediate past Director of Education at the International Society of Radiographers and Radiographic Technicians (ISRRT).
Sub Saharan Africa has proven to be a fertile ground for the provision of workshops on Image Interpretation. A shortage of radiologists coupled with countries not averse to having Radiographers with advanced skills has meant that workshops are very popular and well attended. Whether these workshops succeed in adding a specific skill set for attendees is debatable.
ISRRT has sponsored and/ or run workshops on image interpretation and / or pattern recognition in four countries in the region- Uganda, Rwanda, Malawi and Ghana. Three have been taught mainly by a radiologist and the one on pattern recognition, run by a radiographer. This blog will concentrate on the radiologist driven workshops as these were designed to enhance skills that could be put to use in the field and the ones attended by the blogger. Efforts were made to have rural and remote based Radiographers as the principal participants as they needed the skills more often in their practice. However the other criteria of having a degreed education as a prerequisite served as a juxtaposition to the first, and could have eliminated some of these diploma Radiographers.
The outcomes were clear, to improve the knowledge and skill of image interpretation of the chest, an overview of other regions such as abdomen and skeleton and designed in a train the trainer format so that participants left the workshop with all the materials that were used. It was never explicitly stated that Radiographers attending this workshop would be capable of diagnosing.
The workshops were very intensive usually about 35 hours spread over four or five days and given in a variety of formats, short PowerPoint presentations, Q and A sessions, case of the day, group practical labs and about 3 tests over the period of the workshop. In the last workshop a pre and post-test was administered which was the same test and consisted of 10 cases in which the Participants were asked to identify and describe the pathology. Central to the workshop was the use of a CD "atlas" of images and pathologies. This had been developed over a number of years by Dr Ian Cowan after he had participated in a 2 week image interpretation workshop in the South Pacific sponsored by WHO (and at a time when Radiographers had the wonderful advocate of Dr Harald Ostensen at the World Health Organisation). It contains over 650 images and has been designed for Radiographers to use a resource during practice. It is very comprehensive which sadly has not been given the use and exposure it deserves.
To return to the comment in paragraph one, has this workshop made a tangible difference? Following the Uganda workshop a follow up survey indicated that half the participants were using the CD in their practice or using information learnt to improve their practice. However only 2 individuals offered examples of how they had incorporated this knowledge to improve practice. In Rwanda the post-test demonstrated a nine per cent improvement in knowledge, but the concern remains that is insufficient to consider the workshop a success in achieving its outcomes. Invariably too many attendees arrive at the workshops. An intensive workshop with 25 is far more effective than the 80 plus who turn up despite our pleas. In practical terms it seems like a more cost effective workshop on a per capita basis for ISRRT, but the numbers defeat its purpose. The workshop providers are pushed by the local host to include more information than the chest which was the core to the program. There are also a few very well educated Radiographers who drive the discussions and questions. The silent majority are hard to categorize.
Local radiologists are asked to participate and concentrate on local conditions and pathologies.
In Rwanda the 2 guest radiologists were fulsome in their praise for the Radiographers who were expanding their skills, yet anecdotally later comments made by the same radiologists made it clear that they did not think Radiographers should be reading and that it was in fact dangerous. In Rwanda it became clear to the workshop providers that legislatively, Radiographers would be restricted in their ability to expand their scope of practice.
Uganda is quite different where it is part of their four year undergrad program and a Masters level course is being implemented, spearheaded by a very enlightened radiologist who recognizes the benefits, providing the education is sufficient.
I believe Uganda is a success story and should serve as a benchmark for the region. In Rwanda there were participants from Kenya, Nigeria, Uganda , Tanzania, Ghana, as well as Rwanda who felt very passionately about being able to expand their practice but each country has very different legislations.
Perhaps these workshops only offer false hopes?
Bounce back ability required to delivery patient centred care: August
Daniel Hutton, change manager and therapeutic radiographer at The Clatterbridge Cancer Centre, UK.
The mechanical definition of resilience is the ability to return to the original form after being bent, compressed or stretched. We often hear the adjective 'stretched' as a prefix to NHS professionals. Health care can be hugely rewarding while paradoxically emotionally strenuous. Radiographers/Radiation Therapists, like a spring, need to continually recoil, after being exposed to stressors, ready to go again – ready to put the patient first. Recoil physically after a long tiring on-call shift. Recoil mentally from distractions and interference. Recoil emotionally when we empathise with our patients' pain and difficulties.
Most radiographers/therapists (RTs) manage to do this time and time again. Although like a spring, stretched one time too many, past its elastic threshold, RTs do not always recoil. They do not recoil and are not returned to their original form ready to deliver high quality interventions and patient centred care. They are emotionally burnt out.
Burnout is a cumulative disorder impacting on individuals who interact with the public, effecting emotions, behaviour and thinking. Burnout has been identified as an issue in the radiography profession1,2. It is worth note that educators are also prone to the effects of burnout. The three subsets of burnout are emotional exhaustion, depersonalisation and low professional accomplishment. – This has obvious impact on a radiographer's/RT's energy and ability to deliver technical treatment and interventions, compassionate patient care and to derive job satisfaction from their role.
Low job satisfaction is directly correlated to withdrawal behaviours3. Some Radiographers/RTs may chose to leave the organisation, maybe even the profession. This is bad news at time when a national shortage of skilled radiographers exists in the UK4,5 and an increase to the current establishment is required to meet the demand. Some, although unhappy, will stay as the perceived costs of leaving, financial and social, are deemed too great. So they continue in a profession indeed a vocation in which they are unsatisfied. This is worrying given we know a strong relationship exists between role satisfaction and a patients' perception of the quality of care6,7. In contrast to burnout, compassion fatigue is the idea that individuals can be affected by even one significant interaction. It is therefore imperative that these levels are regularly replenished.
In 2012 the Department of Health8 reported that the NHS should focus attention on the health and wellbeing of their staff in order to provide the best possible service to patients. Not surprisingly better staff health and wellbeing is associated with improved organisational performance and improved patient outcomes9. A key area for leaders and organisations to focus energy and effort is on enhancing the resilience for practitioners.
So what can be done to better support staff, so they can continue to deliver an effective, safe service and patient centred care? Reassuringly there is much more we could do.
Bounce back ability is the phrase coined by ex-footballer Ian Dowie and championed by TV show SoccerAM. It is the capacity to quickly recover from a setback or a negative episode and appears to be a requisite of any sports team after a defeat. It is certainly a desirable characteristic of individuals working in the challenging health care arena. How can we instil bounce back ability into health professionals?
Professionals working in the emotional environment of health care need to regularly, to coin Covey's10 metaphor, "sharpen their saw". Sharpening your saw is about self-improvement, self-care and self-renewal. Leaders and organisations should give professionals the opportunity to do this. In addition to the opportunity individuals need to have the resources and know how to sharpen their saw. It would also be invaluable if individuals could recognise, in themselves and others, when their saw needed attention – that is when their resilience or compassion levels required a top up.
The KASH acronym stands for Knowledge Attitudes Skills Habits and is concerned with the factors influencing individuals' performance. Knowledge and skills are important. With knowledge and experience potentially comes an enhanced ability to cope as practitioners have often seen things like this situation before, they know instinctively how to act and equally how to cope. Attitudes and habits are equally important, practitioners need to adopt a positive default position and develop effective habits to counter the effects of stress.
Neurolinguistic programming (NLP) and Emotional intelligence (EI) are useful resources to manage and counteract the negative impacts of stress. NLP facilitates adopting an optimistic attitude and encourages creating a habit of accessing resourceful states. EI allows individuals to have an increased insight in their own and others' emotions, which when coupled with attitudes and habits enables positive management of emotions and relationships. Mackay et al11 report that radiographers have heightened EI and suggest that EI can be developed.
Professional development of individuals' and teams is a key to building resilience12. Professional development is associated with equipping radiographers with enhanced coping strategies and the vision to approach challenges in an innovative fashion. This approach may lead to a less stressful, more rewarding professional life.
Other interventions commonly practiced include; mentorship, coaching, reflective practice and role modelling. These activities may well have an impact on developing resilience. Probst et al12 state that is important to encourage practitioners to see the bigger picture as means of developing resilience. Along-side encouraging certain attitudes, habits and behaviours in radiographers – we need to discourage perceived stress reliving behaviours such as alcohol consumption, smoking and poor diet.
Can some radiographers be too resilient? Some practitioners are able to cope but may become negative and cynical. So you can be resilient by becoming hard and somewhat uncaring i.e. depersonalised – losing sight why they first joined the profession.
Having purpose is important; radiographers each day should remember why they joined the profession and chose the vocation. They should remember how important their work is and the positive impact they have on their patients or students.
Presenteeism; the act of coming to work when not fit or well to fully discharge one's duties. Presenteeism is a growing concern in the NHS and may come from caring for colleagues and being conscious not to put them under additional pressure by adding staffing pressure. A survey of the radiotherapy workforce, in 2012, reported that over 40% of respondents have attended work "despite feeling unable to fulfil their role"2.
Lord Kelvin warns "if you cannot measure it, you cannot improve it" – it is therefore important to measure staff perceptions of satisfaction and stress and the correlation to patient's perception of treatment and care. The NHS Staff and NHS patient surveys should be used as temperature checks to the culture and practice of the organisation.
The Clatterbridge Cancer Centre NHS FT holds a value of "putting people first". It is telling that it is people rather than solely patients. Radiographers undoubtedly have a responsibly to the patients they treat and care for. There appears, at times, to be a dichotomy of patient first versus individual professional wellbeing. It is worth remembering that radiographers also have a responsibility to their colleagues and importantly, essentially to themselves.
Everyone sits on a spectrum from egocentric to altruistic. In a vocation where the majority fall towards, at times, self-sacrificing, I would encourage practitioners to be a little more selfish, just for a moment. This moment, when the focus is on you and you alone – allows you to sharpen you saw so you can continue to recoil after experiencing stressors in the clinical environment and bounce back to support your colleagues and deliver high quality treatment and care to your patients.
1. Probst H, Griffiths S, Adams R, & Hill C. (2012) 'Burnout in therapy radiographers in the UK', Br. J. Radiol., 85(1017), pp. 760-765.
2. Hutton D, Beardmore C, Patel I, Massey J, Wong H. & Probst, H. (2014) 'Audit of the job satisfaction levels of the UK radiography and physics workforce in UK radiotherapy centres 2012′, Br. J. Radiol., 87 (1039), pp.20130742.
3. Saari LM, & Judge TA. Employee attitudes and job satisfaction. Hum Resour Manage 2004; 43: 395–407.
4. National Radiotherapy Advisory Group Workforce Sub-Group. Radiotherapy provision in England. 2007.
5. Department of Health Radiotherapy Services in England. 2012. [Published 6 November 2012, cited 15 June 2013]. Available from:https://www.gov.uk/government/publications/radiotherapy-services-in-england-2012
6. Mid Staffordshire NHS Foundation Trust. Report of the Mid Staffordshire NHS Foundation Trust public inquiry–executive summary. London, UK: Crown Copyright; 2013.
7. A promise to learn—a commitment to act: improving the safety of patients in England 2013. [updated 10 November 2013, cited 15 May 2013]. Available from:https://www.gov.uk/government/publications/berwick-reviewinto-patient-safety
8. NHS Future Forum (2012) The NHS' role in Public Healthhttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216423/dh_132114.pdf
9. NHS Health and Wellbeing Review (2009)http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_108799
10. Covey SR, The 7 habits of highly effective people, Powerful lessons in personal change, Simon & Schuster, New York, 1990.
11. Mackay SJ, Hogg P, Cooke G, Baker RD, Dawkes T. A UK-wide analysis of trait emotional intelligence within the radiography profession. Radiography 2012; 18: 161–71.
12. Probst, H, Boylan, M, Nelson, P. and Martin, R. (2014) 'Research Article: Early Career Resilience: Interdisciplinary Insights to Support Professional Education of Radiation Therapists', Journal of Medical Imaging and Radiation Sciences, 45 pp.390-8.
Social media and Radiography: July
Sue Beckingham is an Educational Developer at Sheffield Hallam University (UK) and has presented internationally on the use of social media in higher education. She can also be found on LinkedIn.
Over the last 10 years, my role as educational developer in higher education has given me the privilege to work with academics from a wide variety of subject disciplines. My research interest in social media coupled with a passionate interest in technology to enhance learning, has provided the inspiration to explore new innovative ways to augment the learning experience our students may experience and also the way we can engage in professional development as academics. Co-leader of bite sized open online CPD initiatives such as Bring your own Device for Learning and Learning and Teaching in Higher Education Chat have brought educators together from many different disciplines across the UK and internationally to engage in co-learning using social media for continuous professional development (CPD).
The article aptly titled 'Social media: the next frontier for professional development in radiography' recognises that this indeed is a new approach to the way we both engage in professional development but also lifewide learning. The ubiquitous use of mobile technology and increasing connectivity has seen a sharp increase in the use of social media. Mobile technology can enable access to information whenever and wherever we are. As the workplace and public spaces adopt wireless technology, individuals are using the affordances of mobile apps to connect and communicate with others. Social media encourages dialogue and interaction, whereas traditional web pages broadcast information. New approaches to informal learning are enhancing more traditional formal learning and this open approach is making this form of CPD accessible to peers beyond immediate connections.
The paper refers to collaboration as 'the sharing of information, such as medical knowledge, to work together to solve problems or identify issues' and networking as 'interacting with others to develop professional or social relationships'. Networking and collaboration of course have taken place face to face for millennia. The technology that has given access to social media tools has contributed to extending such networks and collaboration by removing spatial and temporal boundaries. Users can communicate both synchronously (real-time) and asynchronously with anyone across the globe. The authors recognise that whilst communication can 'push' messages, the true value is in the social discourse that goes on to discuss, question and challenge the information shared. A ripple effect of shared resources creates curiosity, interest and an opportunity to develop existing and new professional networks.
I felt the article provides practitioners with an authentic and contextual review of how social media is being used in healthcare. Advice to anyone new to using social media in a professional context would be to begin by 'listening' and observing peers in their field and to build an online network with those who bring you value. This may be done by 'listening in' to organised tweetchats on Twitter or discussions in LinkedIn groups; reading blog posts and asking questions via comments; or by watching YouTube videos, listening to podcasts or reading curated collections of information relating to your field in spaces such as Scoop.it, Storify and Pinterest.
Engaging in these new spaces begins with creating user profiles. Making valued professional connections is determined by the professional biography added to a profile. In addition a professional photograph not only enhances a social media profile, it is also recognised as being more trustworthy. The authors quite rightly refer to the importance of engaging with both credible sites and connections. The information shared by an individual using social media very quickly paints a picture of that professional and is often referred to as a digital footprint. It is therefore vital that the online identity of an individual is conducted in a professional manner.
With this in mind, I can confidently advocate the use of social media as a rich space for professional development. Whilst an investment of time is required, this does not have to be onerous and can be undertaken at a time that suits you and your own schedule.
Patient Experience: June 2015
Our blog this moth is thanks to Dr Fred Murphy. Fred is the Senior Lecturer and Programme Leader of the BSc (Hons) Diagnostic Radiography at the University of Salford (UK), and has published extensively in the area of patient experience during diagnostic imaging. You can find him on Twitter here!
It was a pleasure to be a co-author in the qualitative article by Zac Munn et al. Patients' experiences should always continue to be at the very heart of everything we do in medical imaging. Sadly, the true patient experience or the 'emic perspective' is often lost to the desire for scientific knowledge with the focus on the images rather than the patient themselves. I welcome this opportunity to discuss this important topic.
Few papers in this field have tried to fully understand what experiences are encountered when a patient has an MRI scan. Having had one recently I can empathise with many of the personal accounts of patients in these studies. It is not a pleasant procedure being so close to the bore of the scanner and the annoying noise penetrating through your headphones, whilst all the time wondering what pathology might be appearing on the radiographer's monitor. The MRI scan is unlike many other medical imaging procedures because you are totally isolated inside the machine and have no control over what is happening. Can we improve the experience as healthcare professionals? Sure we can, but only if we listen carefully to what the issues actually are.
Zac's study showed the importance of quality patient information which is surely the first step in helping to reduce anxiety before the procedure. There is however perhaps a bigger role to play once the patient arrives in the department. The first reassuring smile, the full explanation and the regular checks on their well-being are all essential parts of reducing patients' misconceptions and increasing their satisfaction with the procedure.
You might have noticed that I haven't mentioned the word 'claustrophobia' yet? This is because I personally doubt if what is reported as claustrophobia is in fact just a transient concern about the enclosed environment. Equally, anxiety, is this the feeling of anxiety over the imaging procedure itself or anxiety over the pending diagnosis, and can we divorce the two?
Therefore if the terms we are seeking to measure are themselves ambiguous, then a quantitative measure alone is unlikely to provide us with answers. I have used novel qualitative approaches in previous research (see the suggested reading list) to try and conceptualise the emic perspective through a different 'lens' and this has led to some interesting findings which I would like to explore further.
Although there has been a focus on MRI, patients' experiences and patients' anxieties are equally as important in all areas of imaging and perhaps we are guilty of neglecting them by assuming that such problems do not exist in other imaging modalities. There is therefore a lot of scope for further debate and further research as we begin to unravel the true patient experience of medical imaging.
Team working and Advanced Practice: May
May's blog is by Nicole Harnett. Nicole is a radiation therapist in Toronto who works between Princess Margaret Cancer Centre and the University of Toronto Department of Radiation Therapy. In addition, Nicole is the PI for the Clinical Specialist Radiation Therapist initiative (Ontario, Canada).
I have finally had a chance to read Woznitza et al's paper "Optimizing patient care in radiology through team-working: a case study from the United Kingdom". Through my lens, I was struck by the impressive approach at quantifying end points and outcomes – this kind of rigour is missing and much needed in our health care system as we are pressed constantly to do more with less. It is even more important, I think, in socially funded systems where following the dollar isn't quite as critical as it is in systems that are pay for service. I am such a fan of Edwards Deming's "plan, do, study, act" model and this is really a great illustration of that at work. I'm not sure that many of us get a chance to study quality control and quality improvement in our pre-certification programs so often these "measuring stuff" concepts are hard to grasp, but this work provides such a tangible and applicable template that can be transferred to anyone's practice.
I remember, from my own experience leading the Clinical Specialist Radiation Therapy Projects in Ontario (looking at the impact of advanced radiation therapy practice), trying to boil something down to its essence so that it could be measured was quite a chore. I think we "old timers" were used validating the worth of things by how they "felt", or because they "made sense" so I clearly struggled in the early going with trying to unpack radiation therapy practice and distill it down to its key, measureable elements. But now that I have done it for so long, everything I look at gets the same treatment – a systematic breakdown of the broader constituents into bite-size, quantifiable elements (you should try it, you might like it!!). And it has paid off in justifying the implementation of the CSRT role in Ontario and resulted in a simultaneous acceptance of a new way of working. And when you think about it, it makes perfect sense. Everything we do in health care is guided by evidence, and practice change/innovation should be no different.
The other thing that struck me about this paper is the apparent buy-in by the entire multi-disciplinary team to find new ways of thinking about practice. The authors paint a picture (whether consciously or subconsciously) of a team working in harmony to achieve the best they can for their patients. And while this scientifically presented paper does not address how the team arrived at this harmonious state, I would be so interested to know how the department orchestrated this change initiative. Again, my experience has shown me that great teams cannot be made, they simply exist and while much has been written on "change management" and how to lead it and navigate it, I have not found any resources that help a dysfunctional (or "nonfunctional") team become functional – certainly not to the level that allows this kind of good work to happen. Nonetheless, change can always be affected – even within our very own practice, and measuring that change is just as important as the change itself.
This paper spoke to my soul – my "measurement" soul" – and I urge you to share it with your colleagues so that we can all get our Deming on.
CPD, learning preferences and radiographers: April
This month's guest blog is from Louise Coleman (@LouiseC_SoR ), Education and Accreditation Officer at the Society and College of Radiographers (UK).
In this month's journal club article by Neep et al (2014) the authors discuss research that attempts to discover (among other things) Australian radiographers' perceptions about their educational preferences. The authors' conclusion is ***SPOILER ALERT*** that no preference was discernible in the selection of radiographers surveyed. Surprised? I wasn't.
It's long been recognised that we all have different learning preferences. Most of us have filled in a learning styles questionnaire at some point in our lives. They're pretty much a mandatory part of the first week of pre-registration education programmes. One of the most common ones is the VARK questionnaire designed by Fleming in 1987*. VARK = visual, aural, read/write, kinaesthetic – There's an example of one here.
Honey and Mumford's (1983*) learning questionnaire is another common one. The categories this time are activist, pragmatist theorist and reflector. As Honey and Mumford are clearly more financially astute than Fleming you need to pay to get a copy of their full questionnaire – what do you mean I could use a well-known search engine to locate a Word document containing the questions and marking scheme? Some universities clearly need help with copyright!
So, did Fleming, Honey and Mumford get the categories right? Do we all fit nicely into their boxes? And, will knowing our learning styles help us decide if we prefer intensive or non-intensive educational programmes? I can only speak for myself but I say no, no and no again.
While I was reading the article I tried to decide if I would prefer an intensive or non-intensive programme of education but I couldn't. Maybe the questionnaire respondents had more information than was described in the article but for me, there were too many unknowns. How, where and when would the content be delivered? What sort of teaching styles would be used and would these mesh with my own preferences? What is my learning preference anyway?
I decided to do a bit of soul searching about the way I've learnt enough to successfully complete educational courses in the past. We all learn best when our environment is right for us. For me this means not too early in the day, having food, a non-panic inducing beverage, the internet, music and a tight deadline to meet. Most face-to-face courses and classrooms don't fit with my preferences. I don't prefer just e-learning either because I enjoy using a juicy pink highlighter pen when I'm reading articles or books. I clearly have a touch of the kinaesthetic about me!
Despite my own preferences I know it's good, and good fun, to experience alternatives to our learning comfort zone. Being flexible enables us to take advantage of learning opportunities when they arise. But it's also good to recognise what works because sometimes we just don't have time to experiment or take a chance. We just need to learn the skills or knowledge to meet our goals.
What's your learning style and do you think you'd prefer an intensive or non-intensive learning experience?
Learning style: A decaffeinated edible procrastinator with a need to be connected to variable mood music late at night.
Intensive/non-intensive: can't decide.
*Don't quote me on the dates, I used an unauthoritative website for my research!