Michelle Tew

Interviewers: Angela Esi Micah and James Buchanan

The Early Career Researcher Interview Series is a new initiative led by the IHEA Early Career Researcher Special Interest Group (ECR-SIG). The aim of this interview series is to showcase the diversity of people in the ECR subgroup in IHEA. By interviewing a variety of ECRs, we hope to describe the many interesting and emerging career paths available to ECRs in health economics, highlight the choices that individuals have made to help them to reach this point in their career, and reveal how ECRs are navigating the various challenges that they face.

The fifth interview of this series is with Michelle Tew. Michelle is a PhD Candidate and Health Economics Research Assistant at the Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne. Her research interests are in economic evaluation, and she is part of the team undertaking economic evaluations for the Medical Services Advisory Committee (MSAC) at the Department of Health to inform decisions about listing of new Medicare items. Angela Esi Micah and James Buchanan, two of the conveners of the ECR-SIG, spoke to Michelle in April 2019 to discuss her career to date.

Hi Michelle, many thanks for staying awake until very late at night in Melbourne to talk to us today! Most of our interviews so far have been with ECRs who have already completed their PhDs, so we are excited to be interviewing a current PhD student today. Could you tell us how you came to choose your doctoral programme, and how you are funding your studies?

I’m currently undertaking my PhD with the Health Economics Unit in the Centre for Health Policy based in the Melbourne School of Population and Global Health at the University of Melbourne. I’m approaching the end of my second year, so I’ve got another year or so to go. My PhD came about in quite an opportunistic way. I previously studied at the same university where I completed the Master of Public Health (MPH) course, specialising in health economics and economic evaluation. After completing my MPH, I was fortunate to find a job as a Research Assistant in the Health Economics Unit. I had been in this role for about two years when the opportunity arose to do a PhD. Although this seemed like a natural progression for me, I did carefully consider whether this was the right path for me, and whether a career in academic research was what I was looking for. I also had to work out if I was able to financially support myself. I really enjoy the environment I am in, and the people who teach and supervise me, Professor Philip Clarke and Associate Professor Kim Dalziel, are incredible mentors and were very supportive of me pursuing a PhD. Something else that was important was that I felt that the research contributions that we made had a policy impact, which made my job really rewarding. With these in mind and also knowing that it was a great way for me to progress and learn, I decided to go for it.

In terms of funding, because I’m an international student there are fees that need to be paid that are quite expensive. Students typically apply for scholarships when they are accepted to a PhD programme, and some of these scholarships are provided by the university. My PhD is funded by the Melbourne Research Scholarship offered by the university and also by two Centres of Research Excellence that I currently work with: The National Centre for Infections in Cancer (NCIC) in Peter MacCallum Cancer Centre and The Centre for Research Excellence in Total Joint Replacement (OPUS) at St Vincent’s Hospital, both in Melbourne. This scholarship covers my fees and provides a stipend. I also still work part-time at the Health Economics Unit, as I did not want to miss out on work experience whilst completing my PhD.

So you are undertaking your PhD on a full-time basis and working part-time at the same time?

Yes, I have a fractional position in the Health Economics Unit. Our team is part of a panel commissioned by the Department of Health in Australia to evaluate new medical services and interventions for the Medical Services Advisory Committee, and I work on a range of evaluations that have been allocated to our group. This is similar to the work that I was doing before starting my PhD, and I really enjoy this kind of work and I did not want to let it go completely. This also means I can still be somewhat immersed in the working environment and was happy to do this alongside my PhD.

What is the general research area of your PhD?

My work focuses on economic evaluation methodologies where I look into the critical components of an economic evaluation; for example, effect of cost inputs and also how outcomes are extrapolated. The research that I work on encompasses two areas: orthopedic surgery and infections in cancer. It is very interesting to be working across these two fields as it has given me the opportunity to learn about the differences in economic evaluation methodologies for surgical and medical interventions and the decision-making process in these areas. I came to work in these two areas partly due to the funding for my PhD, which comes from project grants that were awarded by the two Centres of Research Excellence that I mentioned earlier. These project grants had additional funding to support PhD students. And importantly, because both of these Centres are led by incredible investigators who are top of their class and very supportive, I know I am in good hands and will be learning from the best.

Is the work that you are doing in your PhD related to the work that you were doing as a researcher beforehand?

When I was working as a research assistant I was working on quite a variety of different projects, but there are some commonalities with my PhD. For example, I was working on a cost analysis of a sepsis pathway protocol that was implemented in a cancer hospital in Melbourne, and I am still working with this research group as part of my PhD. Some of my work has evolved from my previous research assistant work, but not all of it. I was keen to be exposed to different clinical areas as part of my PhD as I think it is a good way to learn about the different aspects of health economic evaluation early on in my career. Perhaps my PhD is less conventional than other PhDs in this sense, because I work across two quite different disease areas instead of solely focusing on one.

Could you tell us a bit more about the topic of your PhD? Do you have a fixed title at the moment?

One thing I have learnt over the course of my PhD is that it is constantly evolving. Having said that, I do have a broad idea of what I’m focusing on and the title of my thesis is “Advancing Health Economic Evaluation Methodologies for Health Policy Design”. My PhD research focuses on how we can improve on economic evaluation methodologies using various case studies in orthopedic surgery and infections in cancer. Although economic evaluation is a fundamental component in informing health policy decisions, to be useful to decision-makers there needs to be methodological rigor and consistency in how economic evaluations are conducted. Much of my PhD work to date has focused on the extrapolation of costs and outcomes beyond the timeframes of underlying studies. One of my first pieces of work aimed to understand the impact of incorporating future medical costs in cost-effectiveness analyses, which is important particularly when evaluating interventions in cancer populations. Broadly, my thesis aims to contribute to enhancing methodological rigor in the conduct of economic evaluations and this includes understanding the implications of the lack of rigor, and to make contributions by way of methodological improvements that could lead to better informed decision making and health policy design.

So it’s a broad look at methodology using case studies. Presumably your work isn’t just Australia-focused; your findings will hopefully be applicable in all settings around the world where health technology assessment (HTA) is being undertaken?

Currently, the case studies I have worked on focus on the Australian healthcare system, but my findings are discussed in the context of how they can also be relevant and applied internationally. For example, with my work on future medical costs, although I have used local data, I have explored scenarios in which different types of costs are included in the economic evaluation to reflect variations in HTA guidelines around the world. These variations make it difficult to compare economic evaluation results from one country to another; we’re not necessarily comparing apples to apples.

Of course one could question whether we should compare apples with apples. HTA methods will naturally vary according to social preferences in different countries, but I’m sure this topic will come up in your PhD work.

Yes, that’s right. HTA methods are also dependent on the priorities of each individual funding body and are linked to the context in which funding decisions are made. It is important that information about the type of inputs, timing and who the decision maker is are all accurately reflected and conveyed clearly. It is not enough to just look at the main results or conclusions of economic evaluations to determine cost-effectiveness, we need to understand what has gone into generating the incremental cost-effectiveness ratios (ICERs) to be able to compare results between countries. In the UK, as per National Institute of Health and Care Excellence guidelines, only the costs of the interventions are included in analyses, whereas in the USA, it is recommended that all costs are considered, including current and future costs that are related and unrelated to the intervention. There are variations across international guidelines and it is understandable that these vary according to the scope and societal values. However, these differences do result in variations across the economic evaluation literature which can be misinterpreted when not used in the right context. One of my pieces of work was an economic evaluation of the implementation of a sepsis pathway to manage cancer patients. I found that ICERs changed significantly when the future costs of cancer and other unrelated medical costs were included. This is because patients survive longer with the intervention in place and would naturally incur healthcare costs over their remaining life. To most, it does seem like a rather obvious conclusion, but it is important to think about this when shaping policies and considering the implications of results for future budgets.

There is definitely a lot of interest in this topic at the moment. Just recently a special issue of PharmacoEconomics was published on Measuring Family Spillover Effects of Illness in economic evaluations, and there are a lot of similar arguments made in that context.

Yes, when I have spoken to other academic researchers who do economic evaluation work, there is an understanding that although including all potential costs can make economic evaluations quite complicated, we may need to start including all of these costs because the long-term budgetary implications of adopting expensive healthcare interventions are important for the sustainability of our healthcare system and in the interest of maximising population health gains. I agree that similar arguments, for or against, can be made with regards to the inclusion of spillover effects and it is a fascinating area.

Very interesting…Your work in this area has already being published in PharmacoEconomics right? That’s quite impressive that you have a publication out this early in your PhD career. Can you talk about any challenges you faced due to publishing this early during your PhD process?

Yes, my paper on Incorporating Future Medical Costs: Impact on Cost-Effectiveness Analysis in Cancer Patients was recently published in PharmacoEconomics. I’m doing my PhD with publication so the expectation is that I will have publications by the end of my PhD that I can insert into my PhD thesis. I find the publication process quite daunting but I don’t think that is unique to me. Although it is a very exciting process, it can also be quite frustrating. This is because you spend a lot of time working on this one piece and you submit it to a journal feeling very optimistic about it and it gets knocked back. For instance, this particular paper was rejected by the first journal we submitted to for publication. Rejection can be quite painful because you put so much work into each article. I’m still learning how to cope with rejections and how to approach reviewer and editor comments in a positive way. I have realised that reviewers often provide very good feedback, so it is helpful to ask yourself what it is that you are not conveying correctly or clearly or should take out. It is very easy to want to put so much in because you spent so much time working and re-working on the analysis and reading up on the subject.

Regarding doing your PhD with publication, is there a requirement for the number of papers you have to publish prior to graduation?

At the University of Melbourne, we do not have a set requirement but my personal aim is to have at least six papers. Not all of them need to be published, but they need to be written up or submitted. At the end of the day, the idea is to put all of these papers together, build a cohesive story around them, and craft an introduction and a discussion section that ties it all together. I have several previous PhD colleagues who have done this really well and have published a lot of papers, so they have set the bar really high for me.

That’s commendable especially if you are looking to go into academia.

I realise that in academia, your publishing track record is an important criteria when applying for jobs so I am mindful of this while I am doing my PhD. I want to remain competitive in the field because there are a lot of incredible researchers out there and everybody is doing something really interesting.

Great! Our next topic is related to challenges that you have faced so far – not just in the PhD, although that would be of interest, but also the years beforehand when you worked as a research assistant – are there any challenges that you faced that you would like to share?

The challenges that I have faced are not particularly unique to me and a couple spring to mind. First, one is that although I consider myself quite an organised person, trying to balance a PhD and work is not easy, particularly when I have to do both in the same place. Sometimes it has been difficult to set clear boundaries between work and PhD. I am still learning how to manage this, and I have gotten a better handle on this now. It also helps that I have got a great team of supervisors and colleagues who understand what I am going through and are mindful that I am trying to balance both.

I found that over the course of my PhD, I am slowly learning to become a more independent researcher. This was initially quite a challenging transition for me from being a research assistant to having my own research agenda which is my PhD project. When I started my role as a research assistant, work was very much guided by set deadlines and completing tasks handed down by my supervisors but with my PhD I found that I really had to be self-motivated. Although my supervisors offer extended guidance, I am very much in the driving seat steering this to completion, so I need a lot of self-motivation and to really be quite disciplined.

As a student, what would you share as some things that have worked for you? What has helped you thrive and publish; you sound like you love your program. Can you share some of the things you have done that will be good guidance for other PhD students?

I would say it was very useful having dedicated time to focus on something that I wanted to improve on. For example, blocking off time to study and work on a particular type of analysis. I think your PhD is a great time for you to put your energy into something and learn a lot. This was something that I didn’t get much time to do while I was working as a research assistant because you are guided by deadlines. A PhD offers a great opportunity to read and learn about new techniques or research areas that you are interested in and put it into practice. Personally, the dedicated time to sit down and properly learn something has given me much clarity and I am enjoying this work even more. I am glad to be able to have allocated time – blocks of a week – to work on one thing, and not be too distracted by so many other things.

Also having regular check-ins with my supervisors is very helpful, particularly in the early stages. I remember I was a little bit disorganised at the start of my program and it was challenging to navigate my PhD program because I was suddenly in charge of my own research agenda. It was quite overwhelming but talking to people who understood the process helped. And also remembering to think positively!

You are active on social media. Is there anything you would like to say in terms of best practices for using social media to advance your research?

Well, I don’t use social media as often as some of my colleagues do but I do find it a very useful platform to engage with other researchers in the field or to follow other health economics groups to keep up-to-date with their recent publications or courses and conferences. When I got my first publication I put it on Twitter to help spread the word and to get people to read it. It is a great platform for disseminating my research, to engage others or at least learn about what other people are working on. By following other researchers, you learn about other interesting projects that you could ask them about or collaborate on in the future.

The way we interact with each other is very different from years before compared to what it is like now with the availability of social media. It can be a very useful platform for early career researchers to network with other researchers to share ideas and thoughts. And because we can all interact freely, I think it is as important to pay attention to what others are saying as it is to engage and to do so in a professional manner. With social media, gone are the days when you only get to network at a conference or workshop; now you can network even when you are not face-to-face or when you are worlds apart. A great example is how I got to do this interview; my unit nominated me over Twitter, and I don’t think I would have had this opportunity if it wasn’t for social media! And while I am here, it would be great for me to seize this moment and inform others of how they can find me on Twitter! My Twitter handle is @michelletsp.

Lovely! Wrapping up the interview here, what’s next for you in the PhD process? Also do you have a sense of what you hope to do once you are done with your program?

I have more than a year to go if I am going to finish on time, and I still have a couple more case studies to complete. I am currently trying to finish up writing a paper on using latent class growth analysis to identify unique quality-of-life trajectories in total knee replacement patients and how this can help guide delivery of value-based care. I would be quite keen to submit that soon. I also have a couple of other projects which I am eager to start data analysis on. One of them is an expansion of my quality-of-life trajectories work to quantify variations in healthcare service utilisation and the associated costs of patients with different quality-of-life trajectories, and another is to look at costing strategies to identify future costs or the economic burden of sepsis and other infections in cancer patients. There is still quite a lot more work to be done and I’m quite excited about all of this. The six months before the end of my PhD – it will be all about tying this work together and thinking critically what it all means and framing this into a cohesive piece.

My main goal is to complete my PhD in the next year or so. Post PhD, I hope to work on a variety of projects encompassing pharmaceutical policy and patient-reported outcome measures to broaden my research experience, so I can build my track record and establish a network of collaborators locally and overseas. I am also really enjoying the work that I am currently working on, so I do hope there is scope for me to expand on this. The next few years will provide a good opportunity for me to hone in on where my research interests lie and I am very excited about what’s to come.

Many thanks to Michelle for talking to us today. Interested readers can learn more about Michelle’s work by visiting her profile page. The next interview in the Early Career Researcher Interview Series will be published in September 2019.