Changing clinical practice; balancing research with clinical and other commitments
Dr Louise Fleming is a consultant respiratory paediatrician at the Trust and a clinical senior lecturer at Imperial College. She studied medicine in Manchester before coming back to London (where she grew up) to complete her paediatric training. She went on to undertake a Voluntary Services Overseas (VSO)/ Royal College of Paediatrics and Child Health (RCPCH) fellowship, in The Gambia for a year and a half. After coming back to the UK she applied to do research at the Trust and has been working here and at Imperial College in a variety of roles since then.
We sat down with Dr Louise Fleming to talk about her research and the challenges she has faced.
What inspired you to pursue a career in medicine and research?
Growing up I was interested in science and thought I might enjoy medicine. When I was at school I did voluntary work at a hospital in the physiotherapy department for about a year and a half and that’s where I got a real feel for working with patients and decided this was something I wanted to do.
In terms of research, my interest was sparked by work I undertook in The Gambia. The Department of Health were concerned that there were quite a lot of problems with transfers from the local health facilities to the main hospital. There were many cases of children being transferred too late (and not surviving) and there was also the problem of too many patients being transferred unnecessarily. The Department of Health in The Gambia wanted to do some work around this and find out what was going on with the transfers. Part of my role whilst I was there was to work in the health facilities and track all the patients who were referred up to the hospital and to look at all sorts of things from the reason for their transfer to patient outcomes. In the end, we looked at the records of over a thousand children and wrote up a report for the government which included key low-cost recommendations to improve the transfer process and the management of children in the local health facilities.
When I returned I felt that I really wanted to do more of that kind of work.
What research are you currently working on?
My main interest is in children with asthma. I’m currently working on a number of studies including looking at the different types of asthma children have, the best types of treatments for individuals (rather than treating all children the same) and looking at drug choices, as well as non- pharmacological approaches.
I’m particularly interested in adherence. One of the things we find is that children often have poor control of their asthma because they don’t take their treatment. So my research at the moment is focusing on how we measure adherence, how we know whether they’re taking their treatment or not, finding out why children don’t take their treatment if they’re not taking it, then trying to do something about it.
So essentially it’s about working out, for the individual, what’s the right type of treatment for them, whether they’re taking it and if they are not, how you get them to take it.
What bit of research, current or published, are you most proud of?
I think my most recent publication is something I’m most proud of. We used electronic monitoring devices, or Smartinhalers to measure adherence. I completed the study with Dr Anya Jochmann, a research fellow from Switzerland.
I’m particularly proud of it because it’s a project that I developed and led on. I enjoyed working with Anya who did all the hard work for the study.
The research found that if we measure how much treatment someone is taking using electronic monitors; their asthma tends to get better. However, most children still don’t take their inhalers as often as they should, even when they’re being monitored.
Some children had an improvement in their asthma control while they were being monitored suggesting that they weren’t taking it before. So for this group, we need to find ways to help them to carry on taking their treatment.
Other children continued to have poor asthma control and poor adherence despite the monitoring. For this group we need to find ways of improving their adherence and seeing if they do take their treatment, does it make a difference? Or are they not taking it because they know it doesn’t work?
And then there’s the group of children who despite taking their medication, their asthma control remains poor. For these children, we need to think about stepping up treatment and to consider the use of more expensive and novel drugs.
The research allows us to classify patients and decide what the best management strategy for them is, instead of the usual method which is increasing medication dose without really knowing what’s going on.
The research has led to changes in my own clinical practice. The results have just been published in the European Respiratory Journal and I’m hoping that it leads to a shift in clinical practice, the way that we classify children with severe asthma and how we make management decisions.
I’m also really proud of being awarded a Senior Clinical Fellowship from Asthma UK. I’m planning a study that leads on from my previous adherence work. I want to find out whether using monitors that check both if an inhaler has been used and if it’s being used correctly, can be used in combination with an intervention that addresses concerns about asthma drugs and their side effects, and whether that will lead to improved asthma control.
Have there been any particular barriers or challenges you have faced as a woman working in research?
Working in research, the day is very elastic; it’s not the usual 9-5 hours. When you have childcare responsibilities you are constrained to working within set hours and I found that quite a challenge.
Another challenge of working in research is that you feel like the work is never done. I never get to the end of the day and think “Right, my work is done. I’ll start something else tomorrow”. There’s always a never-ending to-do list.
Also if you’re off from work then no-one does your work for you. So even though it’s great to have autonomy and control over your own work, if I’m not here the work will still be waiting for me!
However, I’ve been very fortunate to work in a department here at the Trust where there are many prominent women and where working flexible hours and working less than full time is seen as absolutely acceptable, which has made it easier.
Have you seen attitudes/culture change or changes in policy/practice since you started your career?
I think there have definitely been changes. When I first started doing research I can’t remember there being any female professors of paediatric respiratory medicine in the UK and now just within this department, there are three.
Overall, I think there have been positive changes in some areas of medicine and research but not in others. As I said, I work with a very supportive team. However, I know that’s not necessarily the case for others and balancing work with other commitments can be challenging.
What do you think needs to be done to help redress the gender imbalances and inequalities seen in research and other STEM-related fields?
More girls are studying STEM subjects at school and university which is great but women are still less likely to remain in academia in those subjects. It’s difficult to pinpoint one reason. It’s likely a combination of things including, lack of job security, long hours (which can disrupt weekends and holidays), particularly when grant deadlines are looming and the many different commitments that need to be balanced.
One of the challenges I face is that I have a clinical job as well, so that is yet another thing that needs to be juggled. Although over 50% of medical graduates are women there are far fewer female clinical academics. There are a number of schemes at Imperial College which help to support female academics. I was fortunate enough to receive an Elsie-Widdowson fellowship which supports academics returning from maternity leave.
Athena Swan has also helped to address work-life balance issues, and not only for women. Mentoring is also a good way to support academics at all levels.
Do you think women are discouraged from entering into or staying in research? If so, what are the main factors?
I think there are issues around job security and the continual need to bring in grant income and publish. There may be times when that is more difficult, for example when returning from maternity leave or when other caring commitments are more demanding. I think more women will be encouraged to stay in research if they are supported through those times and there is a longer-term view of their contribution.
What advice would you give to aspiring female researchers?
If research is something you’re interested in then I would say go for it! It’s definitely a rewarding career. I’ve already touched on the difficulties but actually, it’s great being able to think of really challenging questions, how you’d answer them and then being able to see how that can impact on clinical practice.
There are other great aspects to the role including travelling to conferences, meeting people from all over the world and sharing ideas. You get to share and gain knowledge as well as work with people who are at the top of their field.
Did you have any female role models or any female researchers you look up to?
During my MD my supervisors were Professor Andrew Bush and Dr Nicola Wilson. Nicola was really inspirational, someone who had been working in research for many, many years and doing it at a time when there were very few women in research. She had done it whilst raising a family. She worked less than full time and she managed to get the balance right. She was also never afraid to speak her mind and was hugely respected by everyone.
More recently, Professor Jane Davies has been my mentor and she’s been a real source of inspiration for me as someone who’s been very successful in her field and managed to balance a number of other commitments.
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