Thank goodness for supervision…

I recently read an excellent blog on ‘why supervisions can be hard’ by a former PhD student at Nottingham University. She describes how complex and fraught supervision can be. She starts off by explaining that she had never been asked to sit in front of someone for a full hour and discuss what she thinks. She highlights that the rules for supervision are not explicit before you start, that the relationship with your supervisor is both personal and professional, that you expose yourself during supervision- and its a little scary sometimes (


I started my clinical training as an SLT straight out of school – having just turned 18. And ever since then I have either received some kind of supervision of provided some kind of supervision. I have had individual supervision and peer supervision (in a group). I have been supervised by SLTs, by managers, by nurses, by occupational therapists, by physiotherapists and by psychologists. I have had amazing supervision and not so amazing supervision. I have given supervision to SLTs, nurses, students and psychology assistants. I am sure I haven’t always given great supervision. Long ago, at the very start of my career someone told me that as the supervisee it is up to me to get from supervision what I need. I have also learnt that different people have been able to offer different things in supervision. Some supervisors have offered me clinical ideas, knowledge and problem solving support, others managerial, operational and strategic ideas and others emotional support. With some supervisors I have been able to ask for help with day to day concerns, with others this would not have been appropriate and actually I needed to demonstrate my knowledge and skills in order to gain their confidence in order to push myself or a service forward. Some of these are less tangible but all are useful. And through having so much supervision I have learnt about my own needs and preferences in this area.


As I moved from healthcare delivery into academia I breathed a sigh of relief to know that I would still be having supervision. That this supervision was all mine- no sharing it with anyone else, no politicising it, no focus on the broader service I work in. Before I started my PhD I was lucky enough to  a) know my supervisor from my undergraduate degree b) have a period of time immediately before my PhD where we worked together to put my funding application in and consequently developed a working relationship. Putting all these factors together meant that I approached my supervision with a positive outlook. And my supervisor is wonderful. She made some clear recommendations about how frequently supervision would occur, that writing an agenda in advance and writing minutes up afterwards would be useful. And she checks all my minutes! And reminds me of anything I have missed, or clarifies anything I haven’t quite gotten right in them. My supervisor has always been extremely transparent and clear about what she expects from me. Yet puts no pressure on me – I am able to use supervision how I see fit. I write the agenda.


That is not to say it is always smooth sailing:

– I confess that I have had some moments of paranoia and panic: “What will my supervisor think about my opinion?”, “What will she say about what I have done?”, “Does she think I am stupid!?”. Putting my opinion out there can be daunting. (Of note this is simply imposter syndrome and will NEVER go away, whether I work as an SLT or as academic).

– I realise how genuinely terrible my knowledge of grammar and punctuation is. But my supervisor and I often laugh the root cause of this: I am a child of the 80s, educated in England, so that’s ok. And I think I am getting better at this with her help….

– Getting feedback on written work can be disheartening. I have found that I need to be much more patient in academia. I used to write and send reports that were ‘good enough’ in order to meet a deadline and get a patient what they needed. In academia the focus must be on the quality of the work- and thus I spend a lot longer than I would perhaps want to trying to perfect written work (articles, protocols, ethics applications, thesis chapters). This is a kind of pleasure-pain for me if I am honest- and perhaps should be more fully explored in an entire other blog post!


But these are the exact kind of things that my supervisor is there for. She calls me out when I get something wrong so I don’t make a fool of myself. And she buoys me up when I have a good idea. She is excellent at editing – I mean truly excellent. I am learning SO much from her. And I love to learn. I find the work I produce so satisfying. I am reminded of previous posts where I have compared a PhD to a marathon or to being a parent. It is difficult but so worth it. And my supervisor is my running coach and my conscience. Seriously: thank goodness for supervision!



Intertwined: Dementia and decision making capacity.


This week I have mostly been thinking about decision making capacity.


Decision making capacity is described as the ability to make a  decision. There is little agreement in the research literature on what the specific cognitive components of making a decision are and how to assess these. To date legislation in this area has provided the only real guidance for health and social care professionals in the form of the mental capacity act 2005 and the accompanying code of practice 2007. In summary the mental capacity act explains that a person may only lack capacity if he or she has an impairment of the brain or mind AND has been assessed as unable to understand, recall, remember and express a decision.


This may seem like a major departure from my PhD but it is really intertwined. People with dementia may have difficulties making capacitous decisions. There is a consensus in the research literature  that people with dementia present with progressively less ability in this area as their disease worsens. Yet in the mild to moderate stages they are often able to make decisions. Even in the more severe stages people with dementia may be able to make some decisions if information is presented in a way that they can understand. Understanding is the area where people are most likely to “fail” a capacity assessment. If information is presented visually, using images, context, accessible language and other communication strategies people are often better able to participate. Using these communication strategies is a skill. Speech and language research has demonstrated that communication training can improve the communication of groups of health professionals. Bespoke individualised communication skills training demonstrates improvement in actual conversations. Better conversations with Primary Progressive Aphasia is one such training package.



People with PPA present with a progressive deterioration in communication skills in the presence of otherwise intact cognitive skills. People with PPA are often able to plan, judge and anticipate their future personal and healthcare needs. They may feel anxious and concerned about participating in future decision-making. They might start planning for this future. Supporting people to plan for the future might include developing communication aids that include information about their future decision making. The people around that person may also wish to support them. Supporting people who may end up becoming defacto decision makers (should the person no longer have decision making capacity in relation to a specific decision and have appointed a power of attorney) may include provision of communication training to ensure they are best able to ascertain the persons will and preferences in a specific situation.


So decision making capacity is not a big departure from my work- it is intertwined and integral in the work I do with people with dementia and their families. The forthcoming NICE SCIE guidelines on decision making and mental capacity will provide further support and guidance for us in our daily practice. This is an exciting step – and another part of the conversation.

Girl Power: The origins of Chandler House, UCL.

The entrance to the London Royal Free Hospital School of Medicine for Women.

Speech and language therapists are overwhelmingly female. Don’t ask me why- but I graduated from my training (at UCL) with nearly 40 other women. The building I studied in was and is called Chandler House. And speech and language therapists (SLTs) still train and study here. As do the SLT PhD students. I recently found out the origins of our modest, by UCL standards, building. And it’s quite inspiring. The building was built for a formidable women named Elizabeth Garrett-Anderson. She was by all accounts a determined and passionate person – keen to study medicine at a time when people like Henry Maudsley (famous for improving the standard of mental healthcare) stated that women, such as Elizabeth, should not be educated too much as their feeble minds wouldn’t handle it and they would all be driven to hysteria.


Although women could not study medicine Elizabeth nevertheless  attended all the medical lectures and, tired of having her thrown out, she was allowed to stay. Eventually having completed all the required teaching Elizabeth was the first women to qualify as a doctor in Britain in 1865 when she passed the Society of Apothecaries exam- they promptly forbade further women from taking these exams. But it was not until 1873 that she became the first female member of the British Medical Association.


Chandler House was a consequent development of her successful medical career. In 1874 Elizabeth co-founded the first school of medicine to train women; The London School of Medicine for Women. They occupied a large house around the corner from where Chandler House stands. By 1897 the school had become too big (170 students) and Elizabeth employed her friend and architect JM Brydon to rebuild the building where it currently stands between Wakefield street, Handel street and Hunter street. As dean of the school Elizabeth saw the school join the London University in 1883 and later the Royal Free School of Medicine – part of UCL. Building work on the school finished in 1897/1899.

A decorative stone from outside the building- I haven’t found much evidence of what these symbols mean. My guess is the G stands for Garrett, the B for Brydon (the architect) and the S for Sophia Jex-Blake who co-founded the medical school with Garrett.

The school lives by the love and labour of those who serve her

The ceiling rose.

Elizabeth created a place for people, for women, to love learning. The building has now been divided, and hosts not only part of the UCL department I work in, but also a GP surgery and a Health Centre. Our part of the building previously housed the laboratories and taught chemistry, physiology, anatomy and physics! The building has been praised for its excellent examples of handsome Queen Anne style architecture and there are certainly some lovely features. There is an old board room with rather important wooden paneling, a fantastical ceiling rose and an arch in the hallway reminding us to love learning to keep the school alive.


Elizabeth Garrett-Anderson came from moderately humble beginnings – her father was an entrepreneur who set up and expanded his malting business in Aldeburgh. Elizabeth was the second of eight children. She and her sisters were educated initially at home and then at a boarding school. Her father supported her in her endeavours to become a medical doctor, both financially and otherwise. Yet Elizabeth was not the only impressive Garrett sister. Millicent Garrett was an influential member of the British Women’s Suffrage Committee.


It was only recently that I was part of a twitter discussion (a mini storm) on our role as clinical academics. We all agreed we must advocate and fight for this career pathway. We must push for equal opportunities alongside medical professionals. Elizabeth is an inspiring story of what a women can achieve in mans world. I imagine she would approve of our mission  and would support us in our ventures.

About Elizabeth:

About Chandler House:

I should be writing………….

The main focus of my day to day working life at present is basically writing. Writing thesis chapters (where I feel completely out of my depth), draft articles (that will be rejected and need re-writing) and book chapters (that no-one will read). Writing is, however, interspersed with lots of other things. In fact other things make such frequent appearances that I often find it difficult to get on with writing. Other things manage to raise their heads, wave their hands and emphasise that they are far more important in that moment than writing. This consequently distracts me (often appropriately) from the task at hand and draws me in to an abyss of doing other things.


Now I know it is not unusual to feel disheartened by the writing process. I recognise that getting distracted is also rather common. The best tip I have been given is to just get on with it- shut up and write! This is a writing approach that has been described in detail by academics, creative writers and journalists. There are even blogs dedicated to this approach: My own approach is far more literal. It requires me just to sit down and write whenever I have ANY time at all- it means I can get 45-60 minutes of writing in after I put the kids to bed, before my husband gets home from work (having anticipated this and prepared enough dinner the night before that there are leftovers for an entire week), it means I write in the car whilst the kids are doing their various extra-curricular activities (no chatting with other parents), it means I de-prioritise household chores (I love this bit), it means I don’t chat all day with my work colleagues either (only half a day).

Looking for tips on how to write can become a distraction unto itself. I recently went to a workshop on writing in our department where a number of suggestions and recommendations were made. So, in the spirit of distracting myself with important stuff I thought it might be useful to share a few of them here:


  • PhD students should aim to publish one or two journal articles prior to their vivas; feedback from reviewers an be incredibly useful and give you lots of insights to the kinds of questions an examiner might ask i.e. it is great revision!
  • Looking to the future: New lecturers should aim for 1-6 over census period (2 first author papers per year).
  • There is no recipe to writing
  • Write regularly
  • Schedule time to write and defend it!
  • Write down your writing goals (fold a piece of paper into 12 squares- one for each month of the year, write down your other main deadlines etc, then insert your specific writing aims into each month)
  • Balance the number of reviews you do with the number of papers you write
  • Prioritise 1. proofs and editing, 2. hard deadlines (grant applications/grant reports), 3. revising reviewer comments, 4. first author manuscripts, 5. stuff for other people, 6. blogs
  • Use a spread-sheet to set goals and monitor progress every day (enter the days of the week in one column, your word count goal in another, your actual word count in another, add up total word counts as you progress)
  • Top tips: Get off-line, be regular, take short sprints, write anything as long as its work, do it together


Do you want to be a research site for BCPPA?

Warning shameless advert below:

Are you an SLT with people with Primary Progressive Aphasia (PPA) or potential PPA on your caseload?

Are you interested in conversation training for these people?

Would you like free training in the Better Conversations conversation training therapy program?

Would you like to be involved in an NIHR research project?


Please get in touch via twitter / email:


The Better Conversations with PPA (BCPPA) pilot study is currently underway. It is super exciting and going well. We have enrolled participants and successfully completed the study with them, we have more potential participants about to start. We have students involved in the data collection. It is all progressing.


The three sites I am working with have all been seeing people with PPA for some time. They have been so wonderfully supportive and enthusiastic and continue to be so now too. Unfortunately more recently the SLTs there have experienced difficulties in delivering these services (this probably isn’t a surprise for many SLTs out there reading this). Service reconfiguration and short staffing are not unusual for SLTs working in the NHS. This has meant less participants have and perhaps will be recruited at these sites than we had anticipated. For the project this means we need more sites to try to get closer to the numbers we were hoping for. In order to do this I am embarking on a drive to recruit a few new sites. And an ethics amendment too.


So to start I reviewed the battle plan and have written a call to arms. This has been circulated via a Clinical Excellence Network in the north of England that I have links with. I have also emailed SLTs who have recently been in contact about PPA. My third tactic is to use social media. Twitter has been wonderful to me- as has this blog.


I urge any SLT in England who is reading this and pondering whether they might be interested to get in touch. I am happy to explain how the project works. I would of course support therapists and I would travel to you to deliver all the training. I would provide all the equipment you would need and any assessment forms. I already have ethical approval for the project- this means that the work could start promptly (following a amendment to the ethics and liaison with local R&D to include the new sites).


I have had some very positive reactions and volunteers through my first two methods of recruitment. The troops are gathering force. Better Conversations will prevail. And I shall be updating this blog with my forays into my next ethics amendment. Whoopee (?)

New Years resolutions: Don’t stress – enjoy it!

Every week I make a list of all the things I have to do that week- a to do list. Before Christmas I had a couple of things I hadn’t managed to finish and I thought I would tackle them during the holidays. What was I thinking? Did I think that my 4 year old and my 6 year old would even vaguely allow this? Or that the Christmas holidays include zero social engagement!? Seriously: of course I didn’t do those things. I spent two hours on one morning reminding myself what those things were (basically gazing at my computer screen in a bit of a daze) before I had to return to more food prep whilst simultaneously helping children with two different crafts (they couldn’t agree on the same one so one did clay whilst the other funnelled coloured sand into tiny bottles?!). And then during our various social activities people would kindly enquire if I was working over Christmas? Or if I was allowed to take leave as a student- just reminding me of those outstanding tasks! Of course, I would remind them that yes there is always work to be done. But I can take proper leave because I am also a grown up doing a PhD. And then I felt a bit guilty.


So, now let me explain how this works. I knew this in advance of course but here it is. Yes as a PhD student your time is yours to manage. But there is ALWAYS work to be done! This is both good and bad. And there was one occasion last year where this became a little stressful (where school holidays clashed with a significant milestone in my project). Now I work well with this model in general- I can work when I wish, I am pretty self-motivated and my studies  allow me to be somewhat flexible and pick up kids etc. I really enjoy my PhD but I also feel an obligation to be continuously working. Always on it. Always being productive.


This is where I recall my undergraduate student days- where anytime I sat down to watch TV in my final year I would immediately feel a pang of guilt in the depth of my stomach. What was I thinking: I can’t watch an episode of a terrible but well known TV soap when I have to revise for my finals/write an essay/prepare for placement. And then I also recall the amazing feeling in the first month of working- my weekends were my own! I had NO HOMEWORK! I could frolic through Hackney  (where I then lived) with no one to answer to except myself. Wahooooooo. Obviously that is just being 22 years old. Obviously I am not 22 years old. And I don’t wish to frolic through  Hackney any longer- I am just not hip enough.


As my New Years resolution I have decided to remind myself not to stress about it. I do really love doing my PhD. I feel I can affect the lives of more patients and more therapists with the work I am doing. I can make a difference. I have sat back down at my computer this morning (having been swimming first because it stimulates my brain and I manage my own time whoop) and it really is super interesting. I can’t wait to finalise my lecture for next week and continue writing the piece of work I am currently focused on. And I am basically allowed to manage my own time- be my own boss. So maybe I should just remind myself to give myself some slack. To enjoy it. It is AWESOME! Truly.


What can SLTs learn from cancer trials?


Let me take you back to the beginning. When I first applied for my NIHR fellowship I had to put down a training plan – and cost for this – in my application. At my consequent interview one of the points made by the reviewers was that I would need more training in trials and mixed methods. To this end I have sought out various training opportunities to equip me with more of these skills. Frequently this has meant attending courses not entirely designed for the likes of speech and language therapists. But (I reflect frequently) this isn’t anything new for an SLT. We are often in the minority and by now I quite enjoy the challenge of trying to apply other perspectives to our work- or tweaking concepts to suit what we do!


To address some of this feedback from the reviewers I recently attended a couple of half day courses designed for people involved in running cancer trials.  One of the most important reflections I made during this course was around culture. The course facilitator explained that around 20 years ago there were real difficulties recruiting people to participate in cancer research, Consequently the National Clinical Research Networks were set up. As a consequence of this organisation ( who provide research nurses and so forth to help recruit and collect data) it has become part of routine culture for people to participate in cancer research and around 1 in 6 people with cancer now participate in research. At present we have no such figures for SLT. There are lots of barriers to research in clinical SLT practice. Including culture – perhaps we need to consider how we can address some of these issues. Perhaps we actually need to do more research and more trials in clinical settings to break down this culture.

But culture is not the only barrier. Going on this course challenged my thoughts on what else we could borrow from the cancer trialists. Here are some of my reflections:

  • For starters we need quite a large number of fairly homogenous patients to do a proper RCT. Or perhaps not. Perhaps simply using well matched or groups that are evenly heterogenous. Never the less we need quite a few people- perhaps we need to be attempting more multi-site and international collaborations?
  • When we choose our comparator condition we might want to borrow from practice in cancer trials. Working with some of the rarer cancer groups  does not warrant a “standard practice” comparator. Often there isn’t one that a ) is standard practice and b) is already proven.
  • What about outcomes? We need to choose clinically relevant outcomes. Ones that change practice. Ones that convince the skeptics. But sometimes we aren’t able to quickly or easily measure the exact thing we are affecting. In these cases it’s OK to use a related or ‘surrogate’ measure  in cancer trials. Perhaps we could fall back on confidence more often? Also of note- when you are piloting a research study (phase 2) you may not use the most meaningful measures but those which give you the information quickly in order to plan for the larger phase 3 RCT. Then use the most meaningful ones in that phase 3 trial.
  • The cancer trialists will generally use a phase 1 study to identify maximum dosage- using a 3 by 3 design where 3 people are given a dosage calculated on the minimum required to make a change. If no one has an adverse event then 3 are given a  higher does, this goes on until at least two people have adverse events in the group of 3. The level below is then deemed the maximum tolerated dosage. Can we reverse this model for SLT- can we work out the minimum dosage to make a change by reducing the dosage incrementally? We need to know what the minimum dosage is that commissioners should fund. So can we borrow models like this?
  • In cancer trials tumour size is often used as an outcome. In these cases the tumour is measured at baseline, then during therapy, after therapy and then some time later. If the tumour shrinks by more than 30% this is deemed a partial response, if it increases by more than 20% this is a progressive disease. If it remains within the 20% or the 30% boundaries this is stable disease. Could we consider some of these percentage thresholds as applicable to our progressive patients? It is ever so difficult to measure if therapy is effective in progressive aphasia and stable disease is difficult to define. Perhaps we don’t need to re-invent the wheel? Can we model their response models?





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