Tag Archives: honours

Review and Tips of an Honours Year

Ten months ago I started my honours degree, a Bachelor of Science (Honours). I had just completed my Bachelor of Exercise Physiology, a four year degree, and there was no specific ‘exercise physiology honours’ so I had to do it through the faculty of science. For this degree, the year is made up of full time research under the guidance of your supervisor, who you can find yourself, you submit a literature review, do a talk on that, then submit a final manuscript and do another talk.

This blog will be a bit of a rollercoaster describing my reasons for doing honours, my experiences throughout the year and I will attempt to condense down the most important things I learned throughout the year. This will be somewhat specific to allied health degrees but I hope that there will be something that any prospective honours student can take away from this. I hope my experience helps, and if you have any questions, I’m always happy to chat, just follow the link at the bottom.

Why honours?

This was one of the most common questions I got asked, and fair enough. In my university, the University of New South Wales, the typical path for an exercise physiology student is either to complete the undergraduate degree and become a practitioner, OR if you were interested in research, you would sign up for a masters by research in the faculty. When I first considered doing honours was not aware of any other students looking to do the same thing. So why?

First of all, I realised in my final year that research was something I was interested in but wanted to experience doing it full time before I made any long term decisions. I was talking to a PhD candidate about his experience in research and he mentioned that the best way to set yourself up for a PhD scholarship (if I wanted to go down that path) was to do honours, rather than masters. Initially I didn’t know why, but I trusted him, so decided to sign up. It was only a year. If I didn’t like research, then that was that chapter closed and I hadn’t spent too much time on it.

Choosing a Supervisor

Choosing a supervisor is, I believe, one of the biggest decisions for the whole year. A great paper from Monash University (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0236327) demonstrated that for PhD candidates, the research environment (ie. the group do you the PhD with) predicted success of the student, MORE than the student’s academic ability. I strongly believe this also applies to honours. I was lucky enough to be asked to help out on a project in my fourth year within a large group in my faculty, the McAuley group in the Centre for Pain IMPACT at Neuroscience Research Australia. I had a good experience, and my supervisor, James, is a highly successful researcher and the group was excellent, so I decided to approach them to supervise me for honours. There are countless websites out there discussing what to ask a supervisor, and my only advice is to choose someone you think you’ll like, and who has a good track record of supervising successful students. They’ll often share things like that on their twitter or elsewhere, I saw that my supervisor had multiple students publish 20+ papers in their PhD, which is a very positive sign.

What did I want out of the year?

I really wanted experience, first and foremost, but once I had come to the conclusion I would do honours, I had to work out what I wanted out of it. At the start of the year, I really had no idea what I’d be doing the year after I finished, but I knew I wanted to learn as much as possible, and as many skills (preferably transferrable ones) as possible. However, when I told this to my supervisor, he said, that’s great, but if you want to continue in Academia, you need publications.

I am a firm believer that you should always set a high bar for yourself, and in aiming high, you keep all your options open. My other goal for the year was to come out competitive for a PhD Scholarship. I realised that getting a PhD scholarship was quite difficult (duh), particularly if you were aiming for an NHMRC scholarship, which is one of the most competitive in the country. I figured if I was able to get that, I’d be doing pretty well, and would be well equipped for any other direction I wanted to take (ie. a medical degree).

So were the most important things I learned?

Take notes on all existing literature:

The first 2 months I started searching for every paper in the field, identifying the most important researchers, and summarising the most important papers. Now this was quite tedious, and eventually became quite laborious, but I found that if I didn’t read them in enough detail, and slowly to take notes, I would forget, or not fully understand the main points, which would form what I did in my project for the rest of the year. This is the easiest step to think to rush, because you just want to get started with your project, but extra time spent here until you feel like you know the gaps in the field inside-out is well worth it.

Write to clarify your understanding:

After the first week I had started drafting my literature review, which was due about 8 weeks after I started. The reason I did this was to make sure that everything I was reading was (1) going into my head, and (2) all forming a coherent narrative which would form the basis of my literature review, identifying the key areas my project had to address.

Most people would finish reading, then plan, then write. Although I find that writing helps clarify my thinking, identifying spots where I don’t know enough, which then guides more reading. If you do this early enough you have time to write, and re-write as your understanding progresses. I think I completely re-wrote my literature review about three times. Initially, I didn’t constrain myself to a word limit, any sort of quality, or style, I just wrote. I knew the first time I wrote something, it would not be as concise and clear as possible, because I was only just understanding the concept, and overtime, paragraphs became single sentences, and my work got more and more refined with each re-write.

Get things done early:

I knew I wanted to work on other projects throughout the year, so in order to be asked to do so, I felt I had to show that I was reliable. To do this, I aimed to get drafts done weeks in advance, showing that if someone wanted work done quickly, I was a great person to hand it to. This is advice I would give to any student or researcher wanting more responsibility. I quickly learned all researchers are very time poor, so if someone else is able to help with some work, and do it quickly, they would be very useful. So I wanted to show I would be very useful.

Getting things done early is good and bad. In completing tasks related to honours early, I ended up actually having a lot of spare time, but nothing to fill it with. I love being busy so having all this spare time made me feel like I was wasting time, and gave me a somewhat existential feeling of languishing. However, most normal people have hobbies they spend time on, so I don’t imagine most would encounter this issue.

Do additional work:

Your ability to do additional work really depends on your project, I was conducting a survey online, so once I had established the survey and had started sharing it, I had a lot of spare time. Even when we would be recruiting, it wouldn’t be a very time consuming task. I probably spent on average ~10-15hrs a week on my honours project, leaving about 20 hours to spend on other projects. However, no matter the project there is always space for us to make more time for additional work. I made a point to show that I was a reliable worker and did good work. I handed drafts in early, rapidly responded to feedback, and tried to help out others. After my literature review and introductory talk was finished, I got asked to lead one, and then two additional papers which were unrelated to my honours. This is exactly what I wanted. I grabbed this with two hands and ran with it. These additional projects would become publications (both are currently under review with journals), so this was definitely working towards my number of publications, setting me in good stead for a scholarship.

However, more importantly, another goal for the year was to learn new skills, these projects forced me to do that. These two projects were both on the topic of meta-science, which meant the data collection was not as time consuming as my honours project. However, they both used very different methodologies. One looked at reliability, so I had to a) understand reliability and b) learn how to code and determine it. The other looked at using intervention reporting guidelines to do an overview of all the existing literature on how well studies reported exercise interventions. Both of these required me to learn how to use many different coding packages (using R), run various analyses and create many different figures, all of which I’ll be able to use in the future, but also improved my coding skills remarkably (a very transferable skill).

These additional projects also forced me to be able to manage time effectively, because at any one time I was leading three different projects. My focus would often shift to one when it needed to, then another, and the other, and without even thinking, I ended up staggering them so that they would never all require my full attention at once, making the workload very manageable.

Write early, and write long:

When it came to writing up my thesis, I followed the same principles as when I wrote my literature review. My thesis was limited to 5500 words, and my first draft was over 8000 words. I re-read it, and re-wrote it several times before showing it to anyone (which was another tip I learned, be your own first editor – more about the tips I learned for writing here[link to writing post]). This reduced the burden on my colleagues, but also allowed them to not have to worry about silly mistakes (although they were definitely still there) and focus on the more fundamental flow and concepts in the thesis, which hopefully allowed it to be higher quality in the end.

Summary

Overall, my honours year was incredibly positive. I had a great time during it, I was never incredibly stressed (wild, I know) and I put that down to my organisation, as well as the project I had. I also had a very productive year in terms of publications, I have two first-author papers under review and published four letters to the editor and a first-author editorial just accepted. I am very confident that these achievements have been largely due to finding an incredible group and supervisors, as well as trying to do what I’ve described above.

When is a healthcare intervention actually ‘worth it’ to a patient? – The smallest worthwhile effect

When seeking to identify if healthcare intervention was successful, we typically look for statistical significance in a change to prove to us that the effect wasn’t down to chance. This very good and is most widely used, but simply statistical significance (ie. p < 0.05) is not enough to actually say an intervention was worthwhile. In a study with a lot of participants, it is possible to find a very small change to be statistically significant, and that change may actually have no importance to a clinician or a patient. Let’s use an example, if there is a new drug for blood pressure and it is studied and the researchers find that it reduces blood pressure, with statistical significance, by 1mmHg, this effect does not mean anything clinically, thus, it likely isn’t an intervention you would recommend. However, if another drug reduces blood pressure by 10mmHg and is statistically significant, most people would also consider that change clinically important. That 10mmHg change may be the difference between someone being hypertensive (>140 / 90mmHg) and moving to being in the high-normal category (130-139 / 85 – 89mmHg), which has important reductions in risk of a cardiovascular events. But how much of an effect means something is clinically important, or, what is the minimal clinically important difference (MCID)?

The MCID was defined in 1989 by Jaeschke et al. as “the smallest difference in score in the domain of interest which patients perceive as beneficial and which would mandate, in the absence of troublesome side effects and excessive cost, a change in the patient’s management” (1). In my mind, the key part of this statement is that it is the smallest change which patients perceive as being beneficial, because, at the end of the day, if we as clinicians are giving interventions which are not likely to make the patient feel better, what is the point of administering them?

The MCID has been defined for many different things, from the six minute walk test (6MWT) to ratings of pain, but the methods used to determine the MCID raise some questions about whether they are truly patient centred. Let’s take pain for example, pain can be measured on many different scales but lets use the 11-point numerical rating scale of pain (NRS-P) which goes from no pain to worst pain imaginable. The way the MCID is calculated is by putting patients through an intervention and asking their pain on the 11 point NRS-P at the beginning and end of the treatment, to determine the change which occurred. Then, at the end of the treatment they are also asked how they feel overall on a global rating scale, ie. do they feel the same, slightly worse, much worse or slightly better, or much better. The responses on both these scales are compared, and the change in scores which most closely correlates with feeling ‘slightly better’ or ‘slightly worse’ is determined to be the MCID.

This sounds pretty good on the surface, but it is the researchers or clinicians who decide that patient’s only have to feel ‘slightly better’ in order to see a clinically important change. But what if patient’s want to feel much better and only ‘slightly better’ wasn’t actually worth it for the treatment they went through? These are the major limitations of the MCID, it doesn’t factor in either the patient’s view on what amount of change is important, nor the costs, risks and inconveniences of the treatment which produces the effect.

In 2009, Ferreira et al. (2) coined the term, ‘smallest worthwhile effect’ which is intervention specific and factors in the costs, risks and inconveniences of the intervention. To demonstrate the importance of having intervention specific measures, let’s imagine two patients were to undergo different treatments for their pain, one had major surgery and the other attended a series of educational sessions with a clinician, if the MCID was a reduction in pain by 2 points on the 11-point NRS-P, and both patients achieved a reduction of 2.5 points, would both patient’s be equally happy? Would they both consider that they saw a clinically important change? Probably not, because the surgery has much more severe costs, risks and inconveniences.

When calculating the smallest worthwhile effect, patient’s are explained the intervention, then asked what effect, over and above the effect of no treatment, that would make the intervention worthwhile to them, considering the costs, risks and inconveniences. They are then asked by the clinician, “what if that effect was 0.5 points less? would that still be worthwhile?” and this is repeated until they don’t consider the treatment worthwhile, and thus, the smallest worthwhile effect is established for that treatment. Another aspect of the smallest worthwhile effect is that the hypothetical effect size patients are considering is in addition to the natural history of the condition. For low back pain, most people see a 30% reduction in pain over the first few weeks of a flare up, thus, the effect of any intervention must be over and above this natural recovery or regression to the mean.

The current research (3 & 4) on the smallest worthwhile effect for pain has looked at several different physiotherapy interventions and non-steroidal antiinflammatory drugs (NSAIDS) in low back pain, and there are definitely many treatments beyond this, thus, for my Honours year I’m conducting a study looking to identify the smallest worthwhile effects for different interventions for low back pain.

So why is this important?

The value in knowing the smallest worthwhile effect of an intervention is that it enables clinicians to know, on average, what effect patients consider worthwhile from different treatments. From there, they are able to identify whether those treatments are indeed able to produce that effect. For example, if a patient believes that in order to take a drug for their pain, they would need a 3 point (on an 11-point NRS) reduction in pain in order to make that treatment worthwhile compared to no treatment, considering the side effects of the medication. But the clinician knows that the best evidence shows that the drug in question typically only reduces pain intensity by 1 point, so they may recommend other treatments which have a more favourable cost-benefit profile, or, a smallest worthwhile effect which aligns with the efficacy of the treatment in question more closely. Ultimately, it is crucial that we in research ask patients what they think of the interventions that we are applying to them, and get their input into whether a treatment actually ‘works’ and is worthwhile from their perspective.

References:

(1). Jaeschke R, Singer J, Guyatt GH. Measurement of health status. Ascertaining the minimal clinically important difference. Control Clin Trials 1989;10:407-15.

(2). Ferreira ML, Ferreira PH, Herbert RD, Latimer J. People with low back pain typically need to feel ‘much better’ to consider intervention worthwhile: an observational study. Aust J Physiother 2009;55:123-7.

(3). Ferreira ML, Herbert RD, Ferreira PH, et al. The smallest worthwhile effect of nonsteroidal anti-inflammatory drugs and physiotherapy for chronic low back pain: a benefit-harm trade-off study. Journal of Clinical Epidemiology 2013;66:1397-404.

(4). Christiansen DH, de Vos Andersen NB, Poulsen PH, Ostelo RW. The smallest worthwhile effect of primary care physiotherapy did not differ across musculoskeletal pain sites. J Clin Epidemiol 2018;101:44-52.

P.S. this was to help me solidify my topic in my own head, ensuring I understand it, if you’re interested in it, hit me up