It’s the final countdown: last year of my PhD

Where did the time go?  It feels as though one year has been misplaced somewhere as it’s impossible to fathom that I’m in the 4th year of my PhD.  It has certainly been a roller coaster ride and the idea of the end nearing is both exciting and terrifying.  Thinking through everything that needs to be completed in the next 12 months is overwhelming but at the same time entirely possible.  The key is to stay focussed and disciplined, slow and steady persistence wins the race 😉

The past few years have been such a steep learning curve and I look back at my naive optimistic first year self with a little bit of fondness for blindly jumping onto the rollercoaster.  You can’t really put into the words the experience of doing a PhD or prepare yourself for what lies ahead.  While the challenges are many, the scale tends to tip towards the rewards more often than not.

Just for fun, here are some key words that describe each year of my PhD:

First year:  Optimistic ignorance

Second year:  Sink or swim

Third year:  Writing and waiting and waiting some more

Fourth year:  Persistence and tenacity

While the amount of work to be completed this year is no joke, I know that I can get through it with careful plotting and planning.  I love a good list and even more, love checking things off.

One of the things stressing me out at the moment is the constant enquiry into what I will do post-PhD.  I know most people start a PhD with some ultimate career goal in mind but I honestly started without any idea of where it may lead me.  I know that I love the topic and basis of my research and would love an opportunity to continue doing research in this field, but I have no idea what this looks like in regards to a job.  I feel that this is where Universities let PhD students down.  From all that I’ve heard, it’s very competitive and difficult getting an academic job and there maybe research jobs but only if it fits in with your topic area.  My ideal situation would be to work as part-time clinician (physio) and part-time researcher/lecturer.

So, as I take my final year, one week at a time, I’m trying to keep my heart and eyes open to what possibilities or opportunities there maybe out there in the universe 🙂  While networking is not my strong suit, I will make an effort to seek out and meet people who are working in my field.  You never know what may come from a putting yourself out there! (FYI this last paragraph is a speech from myself to myself…. hope I’m listening haha)


Teaching pelvic floor muscle exercise is like, really tricky

As a Women’s Health Physiotherapist I understand the challenge of teaching a woman to correctly contract and relax her pelvic floor muscles (PFMs).  The concern is not necessarily how strong the muscles are but how well they coordinate especially under high pressure situations.  Previous studies have confirmed the difficulty in teaching the correct technique and have assessed the effectiveness of verbal instruction, paper based resources, technology and various forms of biofeedback.  While these strategies are helpful, there are still some women who really struggle to ‘find’ these muscles.

Most of the studies exploring how to teach PFMT have been based in Western countries, predominantly with well-educated Caucasian women.  These women would have a fairly good understanding of their pelvic organs, anatomy and function.  Now, imagine teaching a woman to contract her PFMs who has no comprehension of her bladder, bowel or uterus and how the muscles work to support them.

One of the main reasons I started my PhD was after I discovered the informational handouts on PFMT in Nepal were incorrect.    Surprisingly, I found that many Nepali physiotherapists, doctors, public health workers and local health workers had been taught misinformation about PFMT.  This set me on a path to help develop new resources and educational workshops on conservative strategies to manage pelvic floor disorders.


Here are some of the examples I’ve been told on how PFMT has been taught to women in Nepal:

  1. To stop-start the flow of urine when emptying your bladder
  2. A supine double leg lift while breath holding
  3. Pull your stomach in and breath hold for 10 seconds
  4. Place your hand between your knees and squeeze them together
  5. Tighten your bottom muscles

Misinformation about PFMT is a common problem globally as I have heard some of these descriptions from women in Australia.  Often when teaching women to squeeze their PFMs we demonstrate with one hand tightening around a finger.  I have been told several times that this confuses Nepali women as a few have gone home and performed their ‘PFM exercises’ with their hands by squeezing them around a finger.

One of the more effective ways of teaching women to find the correct muscles and technique is while performing a pelvic examination.  Asking a woman to squeeze around your finger while give some tactile cuing to the muscle helps her identify the correct muscles and contraction.  This strategy is helpful to women who can access a health professional for an individual assessment and treatment.  However, this is often impossible for many women in low resource settings.  In these settings, women rely on health education from paraprofessional health workers who are often not trained to perform a pelvic examination.

This problem lead me to explore the role of local health workers in providing education to women with symptomatic pelvic organ prolapse.  As part of my PhD I have developed an informational flipchart for local health workers to use and we are currently testing the effectiveness through a randomised control trial.

We can all agree that teaching PFMT is challenging whether in Nepal or Australia or anywhere in the world.  There are women from all countries and settings who face barriers in accessing individual care from health professionals.  Finding ways to reach these women to provide conservative treatment strategies for pelvic floor disorders is crucial regardless of how challenging it is.  So, let’s keep on keeping on…


Judging a book by it’s cover

In research, we know not to form assumptions, be swayed by your own biases or to make unfounded judgements.  This often creates a natural instinct to critically appraise everything that crosses your path.  This has trickled into my real life as now my eyes are drawn to typos and I have become quite skeptical of any overarching statements, such as “this is best burger!” or “I’m starving to death”.  Nup, not buying it! haha Recently, I was frustrated while reading a fictional novel as I couldn’t stop seeing the inappropriate use of American English and British English throughout the book.  At times this can all feel a tad tedious 🙂

As an early career researcher, I have been on a huge learning curve and understand the concept of ‘the more you know, the more you realise you don’t know’. While in my clinical career, I feel confident in my skill set but I also take every opportunity to learn and grow professionally.  So my question is, how do you marry the ability to confidently stand by your achievements and results while still acknowledging the continual pursuit of new knowledge and evidence?

I presented at a conference recently and sat beside a male delegate whom I met that day. Throughout the day, he would write notes then turn to me to explain what each speaker had presented.  To me, this was a classic example of mansplaining!! Nevertheless, it was a long and arduous day.  When it was my turn to present, he gave me a (what I felt was condescending) pat on the back to wish me luck.  As I sat down afterwards, he turned to me and proceeded to mansplain my own presentation arghhhh! I couldn’t help feel that because I am a small, ‘young looking’ female that he felt the need to almost mentor my conference experience.  The whole time I kept wondering what I could do to exude more confidence, maturity and experience.

While we are taught not to judge a book by it’s cover, I can’t help thinking that at times I am judged by my physical appearance and demeanour.  I don’t want to change who I am as a person but I also want to be taken seriously for my professional experience.  Annnnd wearing high heals is not an option 😉

When feasibility trumps robustness

While my PhD journey is nearing the final chapter (writewritewrite) I have naively decided to take on one last research study.  Over the past few years my research has morphed and changed into something quite different than I initially intended but I keep getting pulled back to my original concept.  One aspect of my research has been creating and developing informational resources for health workers in remote regions of Nepal.  It has been challenging but I’ve ended up with a resource that I feel quite proud of (thanks to many many people along the way).  So, now we want to know if this resource will actually have an impact for women with symptomatic prolapse in Nepal.

As a fresh face PhD student, my dreams and ideas were large and lofty 🙂  I wanted to create and develop informational resources then conduct a full RCT to test the impact of the resources.  I quickly learnt that you don’t just pull out any random number for the sample size but there is a sample size calculation that powers your study.  All of sudden my dreams seemed unachievable.  There was no way I could manage a study on my own with such high participant numbers in a country where I don’t speak the language.  I would need to rely heavily on local Nepali people to help me conduct the study and with no money to pay research partners, I had to lower my aspirations.

During the following years, I completed three studies that were all realistic and feasible.  The problem is that they all have poor study designs.  Now that I’m writing up the results, the flaws in study design stare at me glaringly.  The thought of writing up my results into peer reviewed journal articles makes me feel a little anxious and also a tad disappointed in myself.

So now I have one last chance to get it right, but I’m faced with the exact same dilemmas.  It’s not only that I don’t have funding to conduct a full RCT but it doesn’t feel right to add work to an already overstretched health system in Nepal.  Conducting a full RCT would require the local doctors to assess over 200 women at baseline then again 12 weeks later.  I don’t think I can ask them to take the time to help me, even if I was to pay them.

Is it worth designing a study that lacks robustness but is both realistic and feasible given the context of the setting?  Of course I would love to have the biggest and bestest study design but I am just one person and it’s just not going to happen.  I am always a health professional first and researcher second and I still think there are interesting and worthwhile findings in less than ideal research designs.  Sometimes I think studies that are scrappy appear to be more ‘real life’ and take into account that we can’t control every variable especially when working with humans in low resource settings.

I am prepared for my study designs to be criticised and dismissed but I’m not following my research questions in order to win research methodology awards but to really see if we can find any possible solutions in very difficult circumstances.  Go ahead and disagree if you so wish 😉


Hear me ROAR!! Finding your voice

I consider myself a baby feminist and have been on the pursuit of knowledge and empowerment for a few years. Fiercely devouring books on feminism and following women who are fearlessly leading the way, I am only now learning to hear and trust my voice.

It was only recently that it really dawned on me the disservice to myself and society when I don’t use my voice. How can I urge women in Nepal to stand up for gender inequalities and call out injustices when I continue to shy away from any conflict myself. Under no circumstances am I comparing my trivial issues with women doing it really tough in low resource settings, but I have a role to play and I need to practice what I preach! When we don’t call things out we are inadvertently approving them and allowing them to continue without reproach.

So, finding and using your voice can be likened to exercising a muscle. At first it doesn’t quite know what to do and feels awkward but the more you practice the easier it gets. What starts out as a whisper can become a big loud SHOUT!  For me, learning to ROAR doesn’t mean I will ever literally SHOUT, show anger or stamp my feet – my ROAR will involve being calmly relentless 😉

Using my voice doesn’t come naturally but I don’t believe this to be a genetic or biological phenomenon. Little girls are taught to sit quietly, don’t make a fuss and to be good little girls. We are taught to be gentle and gracious and to avoid confrontation. While these are all good human traits, on the flip side we are not taught how to handle conflict or to face injustice head on. As an ‘easy-going’ person it is easy for me to dismiss issues and to just ‘shake it off’. Again, this is also a good human trait, BUT we are not taught when, how and why there are circumstances that we need to stand strong and pursue the matter.

This year has been interesting for me professionally, mostly because I am becoming more sensitive to discrimination and am starting to stand strong and use my voice. There are three specific examples from the past few months in my professional life where I have chosen to use my voice and call out an issue. Interestingly, the initial reaction from all three men was silence and to ignore the matter completely. I realised today that this tactic is using a sneaky ploy to play on ‘feminine good-naturedness’.

Because women are taught to be nice and avoid conflict, I believe feminine good-naturedness is used against women subconsciously by many men in power. It is used initially to push an agenda on a woman, knowing she probably won’t want to make a fuss and will just go along with it. Then if she does raise an issue with the matter, conversation will prey on her good-naturedness illustrating how kind, lovely or generous  she is to go along with things.  Or in my examples, by ignoring my concerns they hope I will just ‘shake if off’ and not take the matter further. When I continued to push forward I was not given an explanation or apology but made to feel like I was being difficult. Nevertheless, I persist, because at this point it is not about the outcome but the principle.

The thing is, I like being a gentle female and have no interest in turning into an aggressive power player. Is it possible to be both firm and gentle, direct and polite, strong and gracious? I believe it is, however tricky this may be. I think the more we practice using our voice the more we learn how to use it in a way that speaks our truth.

Don’t get me wrong, as a baby feminist, when I use my voice it is tight and shaky, my heart races, I’m sweating and I’m also trying to hold back tears… haha (I really hope I get better at it 🙂 )

So, I implore all you lovely ladies to listen and trust your voice and start to use it. Even if it’s a tiny whisper, or even a frowny-face emoji in response to something you disagree with. We ALL must do our part to create societal change xx

Pelvic Organ Prolapse Month – a Nepali perspective

June is Pelvic Organ Prolapse (POP) awareness month and a time for increased engagement and conversation around this common condition. There are many many websites and blog posts on the risk factors, symptoms, treatment options and preventative measures so I think I’ll jump straight to my expertise – POP in Nepal.

There is a high prevalence of POP in Nepal and what is unique to them is that it affects women at a much younger age. The average age of onset for Nepali women is 27 years where in Western countries it is more common in women over 65 years. This means that women of reproductive age who have a POP are faced with challenges such as incontinence, pain and dyspareunia, which in turn negatively effects their relationships and ability to perform housework and paid work. Women living in remote settings can live for decades with reduced quality of life due to limited access to treatment options.

The main reason POP is so common in young Nepali women is that they are responsible for the heavy physical work around the home. Women have to carry very heavy loads of wood, goat feed and water for long distances on a daily basis. This work does not stop when they are pregnant or in the post-natal period. Some other sociocultural factors include early age of first pregnancy, decreased birth spacing and delivering without a skilled birth attendant. None of these risk factors are easy to address, so, how do we help women in Nepal to reduce the risk of developing a POP?? That is a challenging question.

There are many articles written about gender inequalities as being the underlying problem of reduced maternal health in Nepal. The conclusions of these articles always recommend multidisciplinary collaboration and general solutions to help address the inequalities. Reading these urgent calls-to-action may leave one feeling motivated and encouraged but the reality is it can take decades to see change in traditional social norms. As a clinician, I feel particularly helpless reading articles that list sociocultural issues as the predominant risk factors for reduced maternal health. TBH they leave me feeling a little sad 😦

So, what can a clinician do to help women in Nepal at risk of developing a POP? Well, the work I’ve done so far has shown a few potential possibilities. Interestingly, the women I’ve assessed have had good pelvic floor muscle (PFM) strength and function. My initial idea of teaching women to perform regular PFM exercise may not be necessary. More importantly, I think focussing on teaching correct lifting techniques would have a bigger impact. At this stage, we can not expect pregnant and post-natal women to stop performing heavy lifting so we can try and show them a better way to lift that may reduce pressure on their PFMs.

The other strategy is to provide training for local health workers who service remote communities. Local health workers can potentially assess PFM function and POP and fit a ring pessary. They can also provide lifestyle advice and education on strategies to help protect the PFMs and pelvic organs. One of my studies have shown a training workshop for Auxiliary Nurse Midwives with additional one-on-one training was effective in up-skilling knowledge and practical experience for POP management.

One thing that I’ve learnt through my research journey is that there is no one-size-fits-all solutions to addressing POP management. As a clinician I’ve had to rid my own professional biases to try and find solutions appropriate for the unique Nepali context. While POP prevention and management in Nepal is most certainly challenging, it is of upmost importance that we continue to look for solutions and strategies to help women, especially those living in low resource settings.

The struggle is real… :(

I just realised why I’m filled with constant angst these days. After being a physiotherapist for 15 years and am now half way through a PhD, the clinician and researcher in me have drawn battle lines! I’m quite new to the academic and research world and let me tell you that it has been an extremely steep learning curve.

While I am learning and growing in my research skills I am also beginning to see all the flaws in research design and analysis. Planning a robust research design often means controlling variables to allow for comparisons. Depending on what variables are considered to be important or not will dramatically impact the results. Unfortunately, we often go into study with our own biases or take on those from previous studies. I know for sure my clinical experience biases my research and how I interpret other researchers results.

Another factor when designing studies with humans is being able to create something that is feasible for not only the researcher but also the participants. I know that I started my PhD with grand plans but have had to modify the study design to something that is realistic and manageable from a financial, time and human resource point of view.

The third thing I’m learning is that even though I have discovered very interesting findings some of these results can’t be reported because they weren’t an outcome from the research design. Let me give an example of this. During my fieldwork in Nepal, I visited four remote health outposts. In each of these facilities there were posters on the wall about pelvic organ prolapse (my research topic). These are standard government issued posters and the images illustrated the causes and treatment options for a prolapse. What I noticed was that the image showing how to do pelvic floor muscle exercise was wrong and could in fact make a prolapse worse. This was one of the reasons I started my PhD. The other thing I noticed when speaking to the local health workers was that they were all teaching pelvic floor muscle exercise to the community women the wrong way. Both of these points are so interesting and important but because they were mere personal ‘observations’ I can’t report these findings while writing up the journal article. I have tried really hard to find literature, evidence or policy to back up these observations but it has proven impossible.

As a clinician, the process of collecting data has been so interesting and has filled me up with the most beautiful stories from the Nepali women I have met. I am bursting to tell these stories as they are inspiring, challenging and should be considered by both clinicians and policy makers. I feel like the research world doesn’t allow for the story telling behind the data collection process. This is both frustrating, sad and disappointing. There is so much to learn from the process of conducting research (sharing our mistakes and victories) and from the experiences of the participants. In what forum can we share these lessons and stories?


Hindsight is not always everything

It was not until I started writing up the results for a manuscript that I was suddenly and dramatically struck with most certain clarity!

Upon reflection of my research study I found myself starting to question every decision made. This microscopic scrutinisation effortlessly highlighted every flaw, leaving me with a heavy sinking feeling.

In hindsight I can see a far more rigorous study design that would’ve allowed a more useful analysis, resulting with a bigger impact. I can’t help but wonder why I hadn’t thought of these strategies while designing the study. I feel bad that I pursued these ideas without being questioned or being pushed to do better.

I’m not saying that my studies have been a waste of time, in fact the results are novel and interesting. It’s just that when you see the flaws and know you could’ve done better you can’t help but feel a little disappointed in yourself.

The thing I’m learning about research is that there is no perfect study design. The more you read and learn the more you realise there is always a better way to conduct the studies. When working with human subjects there are always complexities in the study design that doesn’t allow for a perfect scenario. Rigorous designs are compromised to follow ethical and logistical considerations. What we set out to do often morphs into something different but feasible.

Hugh Kearns offers support to PhD students and researchers, stating that “Research is not a straight line. There will be setbacks and failures.
Not nice but that’s research. Doesn’t mean you’re a bad researcher.”

Learning that no research is ever perfect and we can always strive to do better is a good mantra to follow as a PhD candidate.

p.s. I am also learning not to beat myself up for the flaws in my work
p.p.s. When feeling down, I recommend spending quality time with a friend of the furry kind 🙂

Communicating in an Academic world: 101

It’s taken me almost two years to finally figure out how to respond to emails from those in the Academic world.  During the first year of my PhD, email correspondence was fraught with misunderstandings, bruised egos and then meetings to clear up the misunderstandings.  Email communication is tricky especially when you don’t know each other personally.  It’s very easy to read between the lines and take meaning where none was intended.

Early on I implemented the ‘Sandwich Method’ and thought it was going pretty well.  When responding to feedback I would reply like this:

  1. Thank you for your feedback…  (bread)
  2. The reason I wrote that was…   (burger patty)
  3. I appreciate your time…   (bread)

Simple, straightforward and to the point, right??  Well, my responses were being misread as me being ‘defensive’ and not taking criticism well.  I didn’t realise I wasn’t allowed to have my own opinion (that is a whole different discussion 😦  )

So, after much reflection, I think I realised where I was going wrong.  A burger of meat and bread is OK but a bit dry.  Put some tomato sauce, mustard, mayo or avocado and an ordinary burger becomes extraordinary.  So, I realised my Sandwich Method needed some tomato sauce.  So, here it goes:

  1. Thank you so much for your helpful feedback…   (bread)  🙂
  2. That was such a fantastic idea you had…  (tomato sauce)   🙂
  3. Even though that’s a brilliant idea, I was wondering though, maybe it could also be… (burger patty)   🙂
  4. Thank you so much for your time, I realise how busy you are…   (bread)  🙂

You may notice the excessive and unnecessary use of smiley faces – this is to definitively illustrate that I’m not upset or being defensive haha

NB// this variation on the sandwich method only works well for communicating with those who have seniority to you.  Personally, I find it completely condescending and when communicating with my peers I tend to just stick to writing like a normal person.

I have only very recently employed this new strategy so I’ll keep you posted as to how it goes.  Maybe you could give it a try and let me know if it’s working for you!

We have ALL experienced racism

With all this media hoopla lately on discrimination, I’ve been thinking a lot about my own situation. Upon deep self-reflection, I know for a fact that I’ve been treated differently because of who I am and how I look.   So who, may you ask, am I? I would say that I am a smallish white woman of average looks with a middle class upbringing and gentle disposition.

You may be wondering how I could ever play the racism card, so let me explain. Throughout my life things have been done to me and for me because of my physical appearance. People treat me a certain way due to their own preconceived ideas and notions of who I am. These superficial judgments are partly responsible for many details in how my life has unfolded.

If racism is being treated differently because of your appearance, then let me give you some examples of potentially racist things that have happened to me in the past few days. Just this week my local café owner gave me a free coffee because I had no cash on me, the nerve! There have also been countless times men have opened doors for me, allowed me to sit down on the train or to pass through when walking on a busy path. These things happen so often, they are ‘normal’ and I have come to expect this behaviour. By what is normal? Do all women get treated this way? I can’t help wondering what if I had coloured skin, was a larger woman or appeared to be of a low economic class, would I still be treated the same way? I just don’t know, and this question is really bothering me.

Being treated differently because of outward appearance was an obvious phenomenon when I was recently in remote regions of Nepal. Collecting data for my PhD took us to the most breathtaking and difficult to access villages where people were not used to seeing white people. Walking along the streets, the local people would curiously stare and children who were bold enough would race up to practice their English. It is often very difficult recruiting participants for research studies but this is not the case in Nepal. Once the word went around that a white medical woman was in town there were far more potential participants then we could possibly assess. There was one 65-year-old lady that really stood out to me as she told the translator her story.  She shared that she had five children but had never been to a doctor before. She also disclosed that her husband was physically violent towards her and she had to sneak out of the house just to come and see me. There were other women who had to walk 6-8 hours over hilly terrain just to come and be involved in the study. These women were often illiterate, never having being to school before and had little say over their reproductive health. The women were so gracious, thanking and blessing me for spending some time with them. It was incredibly humbling to realise the contrast in our life experiences, where I have had every possible opportunity in my education, career and health while they had absolutely nothing.

We don’t have any say over where we are born, into what race or economic class. I am extremely lucky and blessed to be an Australian born Caucasian and into a family who always had more than enough and encouraged ongoing education. In all honesty, I have been very happy to accept all the perks of being a white woman without fully acknowledging how easy I’ve had it. I don’t consider myself a racist but now I can see how openly I’ve accepted preferential treatment because of my appearance and I can’t help feeling that I’m actually contributing to the problem. But, what can I do about this? It’s not my fault I was born into privilege. Well, I have decided that while there are many places in the world where women and children are starving, are living in refugee camps, have no say over their reproductive health or are mistreated because of their physical appearance, I am going to ensure that I give thanks for my many blessings. I am also going to make a big effort to open my eyes and heart to those around me. I can be the person who offers my seat, opens the door and buys a coffee for others rather than always being on the receiving end of grace. You never know, but these small acts of kindness may just create a tiny ripple in the racist culture that we all live in.