Radiation therapists, workplace and culture

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I’m trying to write about radiation therapists. Not the tasks that we do, that’s pretty easy, although most people don’t have much of a clue. I’m trying to explain the relationships we have with each other and what our day-to-day working environment is like. I suspect both are unique. We’re not like our diagnostic radiographer colleagues who can work by themselves. We don’t do that. Our workplace culture is based on tight-knit teams—not only the doctor-physicist-therapist triad but the team that works on the treatment unit.

The closest model I can think of is an operating room. The nurses, anesthetists, surgeons have to work in a kind of dance. This dance relies on what Lorelei Lingard has called collective competence, being able to effectively work and communicate with others. Verbal interaction is key, most errors can be traced back to not talking to each other. It’s similar for radiation therapists. We have innumerable checks and balances, quality assurance steps and protocols, and many of them are verbal. But we also have to, fundamentally, have each other’s backs. It’s a dance of physical movement (moving the patient, moving the treatment couch, moving the equipment) and verbal interaction (I’m doing this now, this next, have you done that?). When we do it well, it flows seamlessly, between ourselves and the patient. When not done well it can cause friction, delays, a lack of patient care and, sometimes, errors.

There may be three of us on a treatment unit, or sometimes more. With breaks and shifts, sometimes just two at a time. If we don’t get on, talk to each other, the work gets harder. We don’t have a choice of who we work with, and we may be working with someone for months at a time. We sit close to them (the treatment consoles are small), check their work (and they check ours), lift and move patients together, and arrange our days (this patient is new, this one is finishing, we need to follow up on this, did you call about the weird noise the machine is making?) We have to trust each other, we have to know the steps.

If you work with someone like this for a few weeks, you often get to know a lot about them. What TV shows they watch, how their commute went, what they have for lunch, what their weekend plans are, their kid’s activities and their upcoming vacation plans. Between patients we chat, we get to know each other, we pass the time, we build our relationship. Our “private” and “professional” lives are not binary – they merge into each other. We need these interpersonal bonds when it gets stressful, when that patient breaks our heart a little, when we have to vent.  They can help sustain us. When we don’t get on, or when we can’t be ourselves at work, it makes what we do harder as well as less safe. The dance slows down, we stumble.

Why am I mulling this over? Because as I write my dissertation I’m remembering times when I was careful what I said at work, the religious co-worker who “didn’t approve of my lifestyle” and an older therapist who ignored my tentative coming out speech and referred to “my husband” (when he talked to me at all). I’ve had recent conversations with gay, bisexual and lesbian (GBL) therapists who have said they “keep themselves to themselves” at work, or “just don’t go there” with some people. There’s ample evidence that having to manage sexual identity at work (to monitor when it’s safe to come out) is common in healthcare, with colleagues as well as patients. GBL workers report more stress and less social support than their heterosexual peers. Covering up who they are is a reality for many, and they are less likely to talk about their partners or life outside work.

Does it matter for radiation therapists? I think it does. We’re not exempt from the same pressures that affect GBL physicians, nurses, pharmacists, other allied health care professionals and our trainees. I might argue that the way we work makes these issues more important. We need to be able to bring our full selves to work, to be able to fully join the dance.

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Writing the dissertation

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After my results section was written (a series of stories) I felt that I’d done most of the creative work, the rest of the dissertation was just framing really, pretty straightforward. I am here to tell you that this was somewhat misguided.

I started with the discussion section next because the results, stories and transcripts were still very much in my head. That was a good idea, but I struggled on a couple of levels. The first was that I kept finding big gaps in my literature review (from my original proposal). My section on “coming out” for example, was about a thousand words. As I wrote, I realised that probably wasn’t enough depth for a doctorate on …. coming out. So, I hit the books again and started to rewrite that section. Turns out there are a lot of models and theories on coming out, that section ended up being half my literature review and about 7,000 words. Cue two months of work.

I also struggled with how to write the discussion. In most projects you’d recap the results and bring in other people’s work to support them as well as revisit your research questions. But I was confused – was my data the interview transcripts or the stories I had written from them? I started off trying to fit them both in and it was a hot mess! My supervisor saved the day by telling me to look at the interviews as the raw data (if we were being positivistic) and the stories as the interpreted and shaped data.

In the end, I set the discussion aside and went back to finish the literature review. It did become a bit of a monster – what ISN’T important when you’re setting the scene? It’s hard to know! I have a lot of words but, damn it, they are good words and I don’t want to slash any! I know there will be an editing session in my future as I get a better sense of what’s extraneous and as my introduction comes together, but for now that massive chunk of wordage represents months of slog and it’s staying.

Next, because I was still scared of the discussion section I wrote the methodology. I did have some text from my proposal but of course had to add what I DID as opposed to what I had planned to do. It wasn’t the same, things didn’t work out as planned, so I had to explain that. I also added a section on reflexivity and this blog was very handy for reflecting back and what I had been thinking as I pondered my research question and how to tackle it. I added sections from the blog as well as my research journal.

I’ve had some issues with my referencing software – it has a mind of its own. I also routinely forget how to format a reference manually despite having done a gazillion. So, I rely on the goodwill of the magical Word plug in. My references are supposed to be APA, mostly it seems to get it right – but what the hell are you doing to my DOIs Mendeley? When I send the drafts to my supervisor they are full of caveats like “I am SO SORRY…I will fix these terrible references!” I can sense her gritted teeth from a few thousand miles away as she once again points out that you don’t capitalise book names (why, though??)

I’m currently on a writing leave and yesterday I sent a draft discussion section to my supervisor. Yes, it contains terrible references as always, but it’s a good start and a weight off my shoulders. I readdressed my research questions and (somewhat surprisingly) found I’d actually mostly answered them. I’m currently reading about truthfulness and credibility as I missed that in my methods. Full disclosure – rereading about subjectivity and standpoint epistemology is actually why I am procrasti-blogging!

There’s a way to go. I have to do a conclusion and introduction next but they don’t loom as large as the discussion section did. So there’s a chance I’ll be defending this year – wish me luck!

 

Explosive Knowledge: Freddie Mercury and my Literature Review

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I am deep in my literature review. Having finished (for now) my results section I made an attempt to write the discussion. It was a sad effort. My results section is my stories, written very much from the heart and from being immersed in the transcripts from my participant interviews. I got very lost in the discussion section, trying to tie the stories back to the literature review I had done for my proposal, about ten million years ago. I kept writing little notes to myself like “add a section on how cancer care is gendered” and “stick in lots more about coming out”. Then I’d get sidetracked for days reading more about cancer and gender (that stuff is interesting!) and forget what I’d been doing.

My supervisor advised me to continue with the discussion – I had the stories in my head, she said, it’s the ideal time to put them in context, relate them back to your research questions. I do have the stories in my head. It’s reassuring. I read about patients being misidentified as sisters, not partners, and I think “oh, that happened to Lisa and Alex” – as if I know them instead of having invented them as characters in a story. It wasn’t enough though – there were big gaps to fill back at the literature review section.

The part I’m building at the moment is on coming out. I originally had a couple of pages in my proposal, which looked fine to me at the time, discussing the metaphor of the closet and how coming out isn’t a one-time act. That small section has grown to many, many pages. I might know more about coming out at this point than anyone in Edmonton (in theory anyway). Watching Bohemian Rhapsody last weekend, I found myself categorising Freddie Mercury’s identity management strategies in my head. He didn’t exactly hide it, most of the time, but used a combination of non-verbal disclosure such as covering and using clues to signal affiliation with a non-heterosexual identity. He was possibly one of the most queer rock stars in history, but some of his fans didn’t pick up the clues, the social context of a rock band served to mute the effectiveness of the message. Similar to Freddie, most LGB people use a combination of methods to come out, a process which is both continual and contextual. See how much fun I am to go to the movies with?

One thing that has struck me, as I wade through my papers, is how this is still very relevant. I did wonder, starting out, if being LGB was still (sometimes) something to be managed at work, or out in the world. In the last few days my news feed has popped up stories about two women being asked to leave a concert for kissing (in EDMONTON!) and a woman in Ontario being kicked out of her church for being in a same-sex relationship. Coming out, for them, had consequences. Watching TV, Drag Race is full of coming out stories, and Transparent is a study in coming out as trans*. At one-point Maura (the lead character, a transwoman) is told not to tell Grandma Rose because it would kill her. “Hey, that’s called ‘explosive knowledge’” I told my fascinated partner, “the idea that coming out could blow up a relationship** and/or cause physical or emotional violence!”

So, the take home message is mainly that I watch a lot of gay stuff, but also that I am mentally and physically immersed in my literature review. I think it was a good decision to do this before my discussion. I hope I will have both the theory and the emotional resonance of the stories available to me when I get there. I’m certainly seeing a lot of connections and hoping I won’t have to do a lot of backfilling if and when I come across an idea or theme I hadn’t  included. Knowledge, explosive or not, that will help me get to the end of this dissertation journey.

 

*I  know, I can’t believe it has taken this long for me to watch it!

** Orne, 2011

 

 

 

 

 

Do I look gay enough?

Last week was my last one at BC Cancer. It was also my last week working in healthcare, after 30 plus years of being within earshot of the radiotherapy treatment machines beeping away I’ll miss the clinical environment. I’m moving provinces, to a job teaching and researching which I know I will love, but still there’s a sense of loss as I say good bye to helping patients find the exit (up one floor), working with clinical educators (universally awesome) and eavesdropping on waiting room conversations (some jaw dropping, some touching). I marked my last week with a lot of goodbyes, an evening of too much beer and some lovely speeches and a photo shoot at the Vancouver Cancer Centre.

The session was organised by our director of patient experience, to take some stock photos for our education material, posters etc. I was asked to take part because of a (mostly) off the cuff remark I made at a meeting a few months ago that I wrote about in this blog. We’d been reviewing our patient education material to see if it included representation for LGB and T people – it mostly didn’t. The images had been carefully selected for ethnic and racial diversity but (to me) no one looked remotely gay enough, the smiling women were all femme and long haired and all the couples were heterosexual. No one seemed to care much except me and a gay colleague – we were videoconferencing and had a lot to say to each other with the microphone safely muted! We both know that representation matters, that LGB and T patients scan the healthcare environment for signs of safety and images on walls and in brochures are important.  Finally, in a fit of frustration, I said that I’d volunteer to pose for a few stock pictures (I think the words I used were I’d be happy to “butch it up”). There was an awkward silence and we moved on to the next agenda item.

So, I was surprised to get an email inviting me to pose as a patient for the photo shoot last week. I felt considerable pressure not to let the side down (especially after my comments!) That morning I spent a lot of time staring into my wardrobe – I skipped the usual floral top and earrings, going for a baseball t shirt and denim jacket. I’d just had my hair cut so spiked it up. Was that enough? Was I identifiable???

The shoot was done in a crowded clinical area with patients coming and going around us. We had a pharmacist in a lab coat playing “the doctor” and a room full of patient volunteers. I felt a fraud as I listened to their stories, one woman with late stage cancer talked about her previous two terrible and current wonderful oncologist and how she’d learned not to put up with bad healthcare professionals (“time is too fucking short” she said). I knew one volunteer from other groups and sprang it on her that she was going to be my partner. She took it well. When the photographer asked for “family” shots he looked at the man next to me and suggested we come in. I grabbed my new lovers hand instead and we went for it.

The first scenario was “bad news” – I was the patient (only fair as my other half had already been through that).  We giggled a lot, but also managed some serious award-winning acting with lots of loving embraces, hand holding and emotion. Then we were told to “talk” to the fake doctor (who did a good job of telling me about my upcoming chemo regime). We were encouraged to use our hands and gesticulate (I guess talking alone doesn’t shoot well) and we took a lot more pictures.

As I left (and hugged my temporary wife farewell) I weaved through actual patients, attending a new patient clinic, some of whom would be getting bad news for real. I hope some of the pictures we took make it into the waiting rooms and elevators, and I hope I looked gay enough – that we looked like a real couple. I’d love to think that in a few years someone sees me in my baseball shirt and denim jacket and relaxes just a tiny bit. That they feel that the cancer clinic is a place for them. It was a fitting way to say goodbye.

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Coming out: Reflections on UKRCO 2017

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So, last week I did a talk at UKRCO 2017 on “Coming Out in Healthcare”. The focus was on patients and healthcare professionals who are LGBTQ, and how we can normalise the coming out process. I had an amazing time at the conference, and met a lot of wonderful people I have so far only known on Twitter. While I was there my friend Rachel Harris gave me some wise doctoral advice – “don’t forget to write this up for your reflective portfolio”.  Not having one of those, I decided to blog it. I’ve been reading and writing (and presenting) on LGBTQ issues in healthcare for what seems forever (although realistically it can only be a year or so) – and overall had a good response. Often LGBTQ people will come up afterwards and tell me about their experiences in healthcare (some funny, some just WTAF). Many straight people will comment that it has “made them think” or the talk “opened their eyes” – which is also gratifying.  The UKRCO post-talk activity was definitely the most positive/funnest/most affirming so far.

The best part was afterwards (on Twitter as well as IRL) talking with a diverse group of people, gay, straight, differently gendered – medical imaging people, radiation therapists, managers and leaders . For example, I met a brilliant undergrad student who was volunteering at the conference and doing research on examining radiographers’ knowledge of care for trans patients. Her impetus was listening (as a first year) to how staff around her had talked about a trans woman who was being treated for prostate cancer. She wanted to change that conversation.  I think what struck me about all the interactions with LGBTQ colleagues were the things we have in common. Coming out stories were shared, some were easy – some painful to talk about even now. There was a lot of discussion about how we manage our identity at work, who knows, who doesn’t – who is cool with it and the inevitable horror stories of the times it didn’t go well (for us as well as for patients).  Most of us remembered patients who were LGBTQ that we clicked with – some of us wore rainbow lanyards, lapel pins or just gave off a strong gay vibe!  We talked about gender – and being gendered – and the difficulty of finding a sweet tailored suit (and not a cocktail dress) to rock up in for the inevitable conference gala dinner.  It was so great to be in the gay-zone and get that sense of support and affirmation – most importantly that my research is on the right track, the stuff I experienced at work hasn’t gone away, and that people are really receptive and keen to learn how to improve care for patients.

In my talk I used a clip from the fabulous Macmillan* “LGBTQ experiences of cancer care” video series where Lesley (a lesbian living with ovarian cancer) talks about her discomfort with knowing some of her nurses were lesbian but closeted. She says “it’s about equality really….” – she is out, why are they hiding that same thing from her? This prompted an interesting side discussion about “should LGBTQ staff HAVE to come out” – where I think (fairly obviously) the answer is “of course not”.  Issues ranged from legislative concerns (where we can’t discriminate against anyone based on sexual orientation etc.) to colleagues saying “well, should I wear a badge that says I am a Christian, Muslim?” One person said that “it’s about being professional” (not talking about their sexual orientation at work) – which ties into a lot of the research that shows it’s often homo, not hetero-sexuality seen as “unprofessional”.

Next week is my comprehensive exam that will assess whether I am ready for candidacy and the research part of my EdD. This week has been a gift in terms of giving me insight into what it is like “out there” and validating my topic as one that is important, relevant and likely to make a change in practice.   Now onward!

*Macmillan have some really good resources, including the recent “Supporting LGBT people affected by cancer” article and the “No one overlooked- experiences of LGBT people affected by cancer” report