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Yale Medicine Thesis Digital Library

Starting with the Yale School of Medicine (YSM) graduating class of 2002, the Cushing/Whitney Medical Library and YSM Office of Student Research have collaborated on the Yale Medicine Thesis Digital Library (YMTDL) project, publishing the digitized full text of medical student theses on the web as a valuable byproduct of Yale student research efforts. The digital thesis deposit has been a graduation requirement since 2006. Starting in 2012, alumni of the Yale School of Medicine were invited to participate in the YMTDL project by granting scanning and hosting permission to the Cushing/Whitney Medical Library, which digitized the Library’s print copy of their thesis or dissertation. A grant from the Arcadia Fund in 2017 provided the means for digitizing over 1,000 additional theses. IF YOU ARE A MEMBER OF THE YALE COMMUNITY AND NEED ACCESS TO A THESIS RESTRICTED TO THE YALE NETWORK, PLEASE MAKE SURE YOUR VPN (VIRTUAL PRIVATE NETWORK) IS ON.

Theses/Dissertations from 2024 2024

Refractory Neurogenic Cough Management: The Non-Inferiority Of Soluble Steroids To Particulate Suspensions For Superior Laryngeal Nerve Blocks , Hisham Abdou

Percutaneous Management Of Pelvic Fluid Collections: A 10-Year Series , Chidumebi Alim

Behavioral Outcomes In Patients With Metopic Craniosynostosis: Relationship With Radiographic Severity , Mariana Almeida

Ventilator Weaning Parameters Revisited: A Traditional Analysis And A Test Of Artificial Intelligence To Predict Successful Extubation , John James Andrews

Developing Precision Genome Editors: Peptide Nucleic Acids Modulate Crispr Cas9 To Treat Autosomal Dominant Disease , Jem Atillasoy

Radiology Education For U.s. Medical Students In 2024: A State-Of-The-Art Analysis , Ryan Bahar

Out-Of-Pocket Spending On Medications For Diabetes In The United States , Baylee Bakkila

Imaging Markers Of Microstructural Development In Neonatal Brains And The Impact Of Postnatal Pathologies , Pratheek Sai Bobba

A Needs Assessment For Rural Health Education In United States Medical Schools , Kailey Carlson

Racial Disparities In Behavioral Crisis Care: Investigating Restraint Patterns In Emergency Departments , Erika Chang-Sing

Social Determinants Of Health & Barriers To Care In Diabetic Retinopathy Patients Lost To Follow-Up , Thomas Chang

Association Between Fine Particulate Matter And Eczema: A Cross-Sectional Study Of The All Of Us Research Program And The Center For Air, Climate, And Energy Solutions , Gloria Chen

Predictors Of Adverse Outcomes Following Surgical Intervention For Cervical Spondylotic Myelopathy , Samuel Craft

Genetic Contributions To Thoracic Aortic Disease , Ellelan Arega Degife

Actigraphy And Symptom Changes With A Social Rhythm Intervention In Young Persons With Mood Disorders , Gabriela De Queiroz Campos

Incidence Of Pathologic Nodal Disease In Clinically Node Negative, Microinvasive/t1a Breast Cancers , Pranammya Dey

Spinal Infections: Pathophysiology, Diagnosis, Prevention, And Management , Meera Madhav Dhodapkar

Childen's Reentry To School After Psychiatric Hospitalization: A Qualitative Study , Madeline Digiovanni

Bringing Large Language Models To Ophthalmology: Domain-Specific Ontologies And Evidence Attribution , Aidan Gilson

Surgical Personalities: A Cultural History Of Early 20th Century American Plastic Surgery , Joshua Zev Glahn

Implications Of Acute Brain Injury Following Transcatheter Aortic Valve Replacement , Daniel Grubman

Latent Health Status Trajectory Modelling In Patients With Symptomatic Peripheral Artery Disease , Scott Grubman

The Human Claustrum Tracks Slow Waves During Sleep , Brett Gu

Patient Perceptions Of Machine Learning-Enabled Digital Mental Health , Clara Zhang Guo

Variables Affecting The 90-Day Overall Reimbursement Of Four Common Orthopaedic Procedures , Scott Joseph Halperin

The Evolving Landscape Of Academic Plastic Surgery: Understanding And Shaping Future Directions In Diversity, Equity, And Inclusion , Sacha C. Hauc

Association Of Vigorous Physical Activity With Psychiatric Disorders And Participation In Treatment , John L. Havlik

Long-Term Natural History Of Ush2a-Retinopathy , Michael Heyang

Clinical Decision Support For Emergency Department-Initiated Buprenorphine For Opioid Use Disorder , Wesley Holland

Applying Deep Learning To Derive Noninvasive Imaging Biomarkers For High-Risk Phenotypes Of Prostate Cancer , Sajid Hossain

The Hardships Of Healthcare Among People With Lived Experiences Of Homelessness In New Haven, Ct , Brandon James Hudik

Outcomes Of Peripheral Vascular Interventions In Patients Treated With Factor Xa Inhibitors , Joshua Joseph Huttler

Janus Kinase Inhibition In Granuloma Annulare: Two Single-Arm, Open-Label Clinical Trials , Erica Hwang

Medicaid Coverage For Undocumented Children In Connecticut: A Political History , Chinye Ijeli

Population Attributable Fraction Of Reproductive Factors In Triple Negative Breast Cancer By Race , Rachel Jaber Chehayeb

Evaluation Of Gastroesophageal Reflux And Hiatal Hernia As Risk Factors For Lobectomy Complications , Michael Kaminski

Health-Related Social Needs Before And After Critical Illness Among Medicare Beneficiaries , Tamar A. Kaminski

Effects Of Thoracic Endovascular Aortic Repair On Cardiac Function At Rest , Nabeel Kassam

Conditioned Hallucinations By Illness Stage In Individuals With First Episode Schizophrenia, Chronic Schizophrenia, And Clinical High Risk For Psychosis , Adam King

The Choroid Plexus Links Innate Immunity To Dysregulation Of Csf Homeostasis In Diverse Forms Of Hydrocephalus , Emre Kiziltug

Health Status Changes After Stenting For Stroke Prevention In Carotid Artery Stenosis , Jonathan Kluger

Rare And Undiagnosed Liver Diseases: New Insights From Genomic And Single Cell Transcriptomic Analyses , Chigoziri Konkwo

“Teen Health” Empowers Informed Contraception Decision-Making In Adolescents And Young Adults , Christina Lepore

Barriers To Mental Health Care In Us Military Veterans , Connor Lewis

Barriers To Methadone For Hiv Prevention Among People Who Inject Drugs In Kazakhstan , Amanda Rachel Liberman

Unheard Voices: The Burden Of Ischemia With No Obstructive Coronary Artery Disease In Women , Marah Maayah

Partial And Total Tonsillectomy For Pediatric Sleep-Disordered Breathing: The Role Of The Cas-15 , Jacob Garn Mabey

Association Between Insurance, Access To Care, And Outcomes For Patients With Uveal Melanoma In The United States , Victoria Anne Marks

Urinary Vegf And Cell-Free Dna As Non-Invasive Biomarkers For Diabetic Retinopathy Screening , Mitchelle Matesva

Pain Management In Facial Trauma: A Narrative Review , Hunter Mccurdy

Meningioma Relational Database Curation Using A Pacs-Integrated Tool For Collection Of Clinical And Imaging Features , Ryan Mclean

Colonoscopy Withdrawal Time And Dysplasia Detection In Patients With Inflammatory Bowel Disease , Chandler Julianne Mcmillan

Cerebral Arachnoid Cysts Are Radiographic Harbingers Of Epigenetics Defects In Neurodevelopment , Kedous Mekbib

Regulation And Payment Of New Medical Technologies , Osman Waseem Moneer

Permanent Pacemaker Implantation After Tricuspid Valve Repair Surgery , Alyssa Morrison

Non-Invasive Epidermal Proteome-Based Subclassification Of Psoriasis And Eczema And Identification Of Treatment Relevant Biomarkers , Michael Murphy

Ballistic And Explosive Orthopaedic Trauma Epidemiology And Outcomes In A Global Population , Jamieson M. O'marr

Dermatologic Infectious Complications And Mimickers In Cancer Patients On Oncologic Therapy , Jolanta Pach

Distressed Community Index In Patients Undergoing Carotid Endarterectomy In Medicare-Linked Vqi Registry , Carmen Pajarillo

Preoperative Psychosocial Risk Burden Among Patients Undergoing Major Thoracic And Abdominal Surgery , Emily Park

Volumetric Assessment Of Imaging Response In The Pnoc Pediatric Glioma Clinical Trials , Divya Ramakrishnan

Racial And Sex Disparities In Adult Reconstructive Airway Surgery Outcomes: An Acs Nsqip Analysis , Tagan Rohrbaugh

A School-Based Study Of The Prevalence Of Rheumatic Heart Disease In Bali, Indonesia , Alysha Rose

Outcomes Following Hypofractionated Radiotherapy For Patients With Thoracic Tumors In Predominantly Central Locations , Alexander Sasse

Healthcare Expenditure On Atrial Fibrillation In The United States: The Medical Expenditure Panel Survey 2016-2021 , Claudia See

A Cost-Effectiveness Analysis Of Oropharyngeal Cancer Post-Treatment Surveillance Practices , Rema Shah

Machine Learning And Risk Prediction Tools In Neurosurgery: A Rapid Review , Josiah Sherman

Maternal And Donor Human Milk Support Robust Intestinal Epithelial Growth And Differentiation In A Fetal Intestinal Organoid Model , Lauren Smith

Constructing A Fetal Human Liver Atlas: Insights Into Liver Development , Zihan Su

Somatic Mutations In Aging, Paroxysmal Nocturnal Hemoglobinuria, And Myeloid Neoplasms , Tho Tran

Illness Perception And The Impact Of A Definitive Diagnosis On Women With Ischemia And No Obstructive Coronary Artery Disease: A Qualitative Study , Leslie Yingzhijie Tseng

Advances In Keratin 17 As A Cancer Biomarker: A Systematic Review , Robert Tseng

Regionalization Strategy To Optimize Inpatient Bed Utilization And Reduce Emergency Department Crowding , Ragini Luthra Vaidya

Survival Outcomes In T3 Laryngeal Cancer Based On Staging Features At Diagnosis , Vickie Jiaying Wang

Analysis Of Revertant Mosaicism And Cellular Competition In Ichthyosis With Confetti , Diana Yanez

A Hero's Journey: Experiences Using A Therapeutic Comicbook In A Children’s Psychiatric Inpatient Unit , Idil Yazgan

Prevalence Of Metabolic Comorbidities And Viral Infections In Monoclonal Gammopathy , Mansen Yu

Automated Detection Of Recurrent Gastrointestinal Bleeding Using Large Language Models , Neil Zheng

Vascular Risk Factor Treatment And Control For Stroke Prevention , Tianna Zhou

Theses/Dissertations from 2023 2023

Radiomics: A Methodological Guide And Its Applications To Acute Ischemic Stroke , Emily Avery

Characterization Of Cutaneous Immune-Related Adverse Events Due To Immune Checkpoint Inhibitors , Annika Belzer

An Investigation Of Novel Point Of Care 1-Tesla Mri Of Infants’ Brains In The Neonatal Icu , Elisa Rachel Berson

Understanding Perceptions Of New-Onset Type 1 Diabetes Education In A Pediatric Tertiary Care Center , Gabriel BetancurVelez

Effectiveness Of Acitretin For Skin Cancer Prevention In Immunosuppressed And Non-Immunosuppressed Patients , Shaman Bhullar

Adherence To Tumor Board Recommendations In Patients With Hepatocellular Carcinoma , Yueming Cao

Clinical Trials Related To The Spine & Shoulder/elbow: Rates, Predictors, & Reasons For Termination , Dennis Louis Caruana

Improving Delivery Of Immunomodulator Mpla With Biodegradable Nanoparticles , Jungsoo Chang

Sex Differences In Patients With Deep Vein Thrombosis , Shin Mei Chan

Incorporating Genomic Analysis In The Clinical Practice Of Hepatology , David Hun Chung

Emergency Medicine Resident Perceptions Of A Medical Wilderness Adventure Race (medwar) , Lake Crawford

Surgical Outcomes Following Posterior Spinal Fusion For Adolescent Idiopathic Scoliosis , Wyatt Benajmin David

Representing Cells As Sentences Enables Natural Language Processing For Single Cell Transcriptomics , Rahul M. Dhodapkar

Life Vs. Liberty And The Pursuit Of Happiness: Short-Term Involuntary Commitment Laws In All 50 US States , Sofia Dibich

Healthcare Disparities In Preoperative Risk Management For Total Joint Arthroplasty , Chloe Connolly Dlott

Toll-Like Receptors 2/4 Directly Co-Stimulate Arginase-1 Induction Critical For Macrophage-Mediated Renal Tubule Regeneration , Natnael Beyene Doilicho

Associations Of Atopic Dermatitis With Neuropsychiatric Comorbidities , Ryan Fan

International Academic Partnerships In Orthopaedic Surgery , Michael Jesse Flores

Young Adults With Adhd And Their Involvement In Online Communities: A Qualitative Study , Callie Marie Ginapp

Becoming A Doctor, Becoming A Monster: Medical Socialization And Desensitization In Nazi Germany And 21st Century USA , SimoneElise Stern Hasselmo

Comparative Efficacy Of Pharmacological Interventions For Borderline Personality Disorder: A Network Meta-Analysis , Olivia Dixon Herrington

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INFORMATION FOR

  • Residents & Fellows
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Student Research Resources

Resources and forms to help you navigate student research opportunities!

Required Formatting and Components of the MD Thesis

Examples for reference section formatting, avoiding the risk of copyright violation and liability when submitting your md thesis, instructions for submitting a thesis to the yale medicine thesis digital library, thesis depositors declaration form, evaluations of advisor.

In general, one topic is appropriate for the thesis, but it is recognized that some students may have performed several projects in parallel under the supervision of their mentor. If the student elects to include more than one study in the thesis, it is recommended that an attempt be made to integrate the topics into one coherent presentation. In rare cases where this goal cannot be achieved, it may be acceptable to divide the results section into different portions (or “chapters”). However, to be consistent with Yale formatting requirements, a thesis may not contain more than one abstract, introduction, statement of purpose, methods, results, and discussion section. It is not acceptable to submit a published or submitted manuscript in lieu of the thesis requirement. The formal thesis is presented as a digital document (PDF) during the graduation year. It must adhere to the following formatting and content requirements. These aspects of research are critical in making the work sound, error-free, and impactful for communities of interest. Recognizing that students may have uncertainly regarding how these guidelines relate to their thesis, OSR will be happy to answer any questions that may arise. Additionally, students may find it useful to consult the Equator reporting guidelines to enhance the quality and transparency of their theses. The Yale MD Thesis is a doctoral thesis that assesses research competencies as the basis for the conferring of a doctoral degree. Therefore, a minimum requirement of 30 pages (exclusive of title page, abstract, acknowledgements, table of contents, figure legends, references) is considered the minimum acceptable length.

  • Font: 10-12-point font should be used.
  • Line spacing: Body paragraphs and tables should consist of double-spaced text. Single spaced text may be used within block quotations, footnotes, and bibliography.
  • Margins: 1.5-inch margins on the left with one-inch margins on the remaining three sides. These margins apply to text, full-page images and illustrations, and tables.
  • Figures: Illustrative information, schematics, and representative data should be included as figures. Each panel in a figure should be labeled. Legends should describe each panel in detail in a 9-point font or greater and positioned below the figure to which they refer. Figure legends do not count towards the 30-page minimum.
  • Page Numbers: Each page in the thesis should be numbered except the title page, abstract, acknowledgements, and table of contents. The numbering should start at page 1 of the first page of the instruction be placed either at the top or bottom center, or at the top or bottom right-hand corner, at least 1/2 inches from any edge.
  • Minimal page requirement: Most Yale MD theses average 40-80 pages of text. A minimum of 30 pages of text excluding title page, abstract, acknowledgements, table of contents, figures, legends, and references is required. Tables may count towards the minimum page requirement.

Required Components

  • Title page: Title should not exceed 100 characters including spaces between words. The title page is not included in the 30-page minimum.
  • Abstract page: As described below. The abstract is not included in the 30-page minimum.
  • Acknowledgements: Personal and faculty acknowledgements, grant support, departmental support, etc. The acknowledgements page is not included in the 30 page minimum.
  • Table of Contents: with page numbers for each section. The table of contents is not included in the 30-page minimum.
  • Introduction: A thorough, complete, detailed, critical review of the literature that contextualizes and cites the work of previous investigators. This section should describe the state of the existing knowledge, provide rationale for the study, identify knowledge gaps, and frame the contribution of the thesis to medicine. The introduction is included in the 30-page minimum.
  • Statement of purpose: Specific hypothesis if appropriate, and specific aims of the thesis. The statement of purpose is included in the towards the 30-page minimum.
  • Student Contributions: Describe in detail exactly which procedures, methods and experiments were conducted by you and which procedures, methods and experiments, generation of data, or production of reagents, were performed by other members of the study team. It is not sufficient to state that this information may be mentioned elsewhere. It must be summarized here. It is recognized that students may often be completing a portion of a larger work. A statement detailing precisely what was done by the student and what was done by others does not detract from the thesis but is necessary for academic honesty.
  • Ethics Statement: Include information regarding the ethical and responsible conduct of research.
  • Human Subjects Research: If relevant, include explicit information regarding Institutional Review Board approval and informed consent. If the study had a waiver of consent, this exception must be clearly stated. Information regarding inclusion of historically vulnerable populations as research participants should be included here.
  • Laboratory Animals: For studies involving laboratory animals, include an explicit statement regarding study approval from the Institutional Animal Care and Use Committee. Include information regarding the species, strain, sex, and age of laboratory animals in this section as well.
  • Methods Description: Provide information regarding the materials and methods used in the study. Each method should consist of its subheading and paragraph and be described in detail that is sufficient to allow its replication by an investigator who did not participate in the study.
  • Statistical Methods: The last paragraph in this section should present the methods used to derive results. As needed, describe any data preprocessing such as transformation and normalization. Describe how outliers were defined and handled and present descriptive statistics as appropriate. The number of sampled units (ie, “n”) and significance (ie, “P”) should be reported for each statistical comparison. Continuous variables that are normally distributed may be presented as mean + standard deviation. Continuous variables that are asymmetrically distributed should be presented as median + interquartile range. All statistical tests should be clearly described and include information regarding testing level (alpha) and one- or two-sided comparisons. Corrections for multiple testing should be addressed and reported. Any novel or complex data algorithms should be clearly described and appropriately referenced.
  • Transparent reporting of results: All primary data related to the thesis topic should be presented. Important data should be enumerated in figures or tables. For ease of review, it is preferred that figures and tables be included in proximity to their callout in the text. Alternately, tables and figures can be presented separately after the discussion but, if possible, it is advantageous to the reader to include these components in the body of the results section, as occurs in research publications. The results section is included in the 30-page minimum.
  • Discussion: This section presents thorough and detailed interpretation and analysis of data, conclusions drawn, and framing of observations with the larger scientific literature. Limitations should be addressed, as should alternate interpretations and how the thesis may inform future studies in the field. Whenever relevant, a discussion of how the thesis may or already has meaningfully impact(ed) communities of interest should be included here. The discussion section is included in the 30-page minimum.
  • Challenges & Limitations : A brief discussion of methodologic, operational, and other challenges relevant to the research presented in the thesis. Please also include a brief discussion of how these challenges were addressed. Recognizing that all research projects have important limitations that readers should consider in interpreting the results, please include a brief discussion of the limitations relevant for your research. This section is included in the 30-page minimum.
  • Dissemination: Please include efforts made to share findings with the scientific community (through oral presentation, peer-reviewed publications, and other venues) and the larger community including patients. This section is included in the 30-page minimum.
  • Figure References and Legends: Figures must be cited sequentially in the text using Arabic numerals (for example, “Fig. 7”). Provide a short title (in the legend, not on the figure itself), explanation in sufficient detail to make the figure intelligible without reference to the text, and a key to any symbols used. Figures and legends are not included in the 30-page minimum.
  • Tables: All tables should be double-spaced, self-contained, and self-explanatory. Provide brief titles and use superscript capital letters starting from A and continuing in alphabetical order for footnotes. Tables and their legends are included in the 30-page minimum.
  • References: We strongly recommend the use of bibliography software such as Endnote for managing the references. References should be formatted according to New England Journal of Medicine Style. References are not included in the 30-page minimum.

It is acknowledged that theses in the area of medical humanities, ethics, history, and related fields may not obviously adhere to the above requirements. In this case, the thesis will likely replace the “hypothesis” with a “claim” based on evidence gleaned through literary, historical, and ethical research. The first paragraph of the Methods should still contain information about the student’s contribution. The subsequent paragraphs should describe the artistic, literary, or historical databases and methods used to gather the “evidence” presented in support of and contrary to the central claim. The discussion and remaining sections are the same and the 30-page minimum applies. If you have questions about how to best frame your thesis, please contact OSR.

Abstract Page

Standardized format for the abstract of each MD thesis is required. This format must be followed for all abstracts published in the Yale Medicine Thesis Digital Library. These abstracts will not be reviewed for content. It is the responsibility of the student investigator and the faculty advisor to prepare the abstract. Faculty sponsors provide approval of the abstract when they approve the final version of the thesis. These abstract instructions are to be used for the digital library submission.

  • Abstracts should be formatted with 1.5-inch margins on the left and 1-inch margins on the remaining three sides. All text, including title page, must be double-spaced.
  • Abstracts may be no more than 800 words in length, not including title and author information.
  • Titles should be brief, clear, and carefully chosen. The title should not exceed 100 characters including spaces between words. Capitalize the entire title, using no abbreviations.
  • Authors’ names are to be written in full, omitting degrees. The student author's name shall be first. If the faculty sponsor also qualifies as an author, their name should be last. If the faculty member has been only a sponsor, his or her name should appear in parentheses after the name(s) of other authors as follows: "(Sponsored by...)". Other collaborators should be listed after the student's name and before the faculty sponsor's name. Immediately following the faculty sponsor's name, designate section (if any), departmental affiliation, institution, city, and state (Yale University School of Medicine, New Haven, CT) (see examples in the Thesis Guide ).
  • For thesis work performed at another institution, designate the senior author's departmental and institutional affiliation. In parenthesis, indicate the Yale faculty sponsor and institutional affiliation with the phrase: "Sponsored by..." (see examples).
  • A statement of the hypothesis or goals and specific aims of the study.
  • A statement of the methods used.
  • A summary of the results presented in sufficient detail to support the conclusions. Include actual values with statistics, if appropriate.
  • A statement of the conclusions reached.
  • Do not use subtitles, e.g., methods, results.
  • Do not include graphs, references to other publications, or acknowledgement of any research grant support. A single short table of results can be used if appropriate.
  • Abbreviations may be used in text only if defined initially by placing them in parentheses after the full word (or phrase) first appears in the text. Abbreviations may not be introduced in the title.
  • Non-proprietary (generic) names are required the first time a drug is mentioned, written in small letters. Proprietary names are always capitalized, e.g., acetazolamide (Diamox).
  • Completed abstracts must be approved by faculty advisor.

Thesis Assessment

The thesis assessment will assess student performance on the following domains using a 1-5 Likert Scale.

  • Significance
  • Rigor of Prior Research
  • Methodologic Rigor
  • Responsible Conduct of Research
  • Organization and Clarity of Text
  • Presentation of Data
  • Interpretation of Data
  • Student Effort
  • Dissemination to Communities of Interest

Likert Scale:

  • Not Acceptable

The vast majority of YSM students receive scores of 2-3 across these domains. Scores of 1 are considered truly outstanding. Scores of 5 are highly unusual and indicate the presence of critical deficiencies. Students receiving a score of “5” in any domain will be referred to OSR and the Progress Committee for remediation in order that they may stay on track to graduate.

Journal Articles

1. Yalow, R.S., and Berson, S.A. 1960. Immunoassay of endogenous plasma insulin in man. J. Clin. Invest. 39:1157-1175.

2. Gardner, W., and Schultz, H.D. 1990. Prostaglandins regulate the synthesis and secretion of the atrial natriuretic peptide. J. Clin. Invest. In press.

Complete Books

3. Myant, N.B. 1981. The Biology of Cholesterol and Related Steroids. London: Heinemann Medical Books. 882 pp.

Articles in Books

4. Innerarity, T.L., Hui, D.Y., and Mahley, R.W. 1982. Hepatic apoprotein E (remnant) receptor. In Lipoproteins and Coronary Atherosclerosis. G. Noseda, S. Fragiacomo, R. Fumagalli, and R. Paoletti, editors. Amsterdam: Elsevier/North Holland. 173-181.

5. Standardized format for the abstract of each MD thesis is required. This format must be followed for all abstracts published in the Yale Medicine Thesis Digital Library. These abstracts will not be reviewed for content. It is the responsibility of the student investigator and the faculty advisor to prepare the abstract. Faculty sponsors provide approval of the abstract when they approve the final version of the thesis. These abstract instructions are to be used for the digital library submission.

Your MD Thesis represents an academic milestone. The protection of your thesis copyright exists from the time your work was created in digital form. Every article, book, or web page you used in conducting research and writing your thesis is also protected by copyright. When you download a single personal copy of a research article or cite a short passage, this scholarship is protected by the legal concept of fair use. A basic understanding of copyright protections and fair use is found at www.copyright.gov . Yale University also provides a guide to copyright protection and fair use: http://ogc.yale.edu/legal_reference/copyright.html .

Section 107 of the U.S. Copyright Law describes how to determine if a particular use of copyrighted material is fair. However, the distinction between what is fair use and what is infringement is not always clear or easily defined. Copying an image from an academic e-journal and citing the source does not substitute for obtaining permission to reproduce the image. Many publishers use www.copyright.com to grant reproduction rights of their articles to authors.

ProQuest/UMI and the Yale Medicine Thesis Digital Library may elect not to distribute your thesis in the absence of evidence that permission or reproduction rights have been secured. Providing evidence of permission or reproduction rights is a student author responsibility. Examples encountered in MD Thesis research that require documentation of reproduction rights include but are not limited to:

  • Sections of published survey instruments or questionnaires.
  • Complete journal articles or other complete scholarly works [Note: The publisher Elsevier does allow graduate student authors of a journal article prior to graduation to reproduce their article in a thesis].
  • Image, graphic, or pictorial works from publications where the author has transferred copyright to the publisher, a common occurrence.

The safest course to avoid a delay in thesis is to avoid using published images without obtaining permission. It is almost always possible to cite a source and expect that readers can find the figure, chart, or image in the published version of the referenced work. Research faculty who transfer copyright to a publisher of their article are no longer the copyright holder and are unable to grant permission for reproduction. To circumvent this issue, the student or mentor may be able to offer unpublished images from their group’s image collection.

When it is impracticable or prohibitively expensive to obtain permission through the publisher or the Copyright Clearance Center (www.copyright.com), students should avoid using that the material, unless they have obtained a written legal opinion that fair use would apply to the situation. Neither the Office of Student Research nor the Yale Library can supply legal advice on copyright and fair use. If there is any doubt, it is advisable to consult the Yale University Office of the Vice President and General Counsel at 432-4949. If a student is unable to obtain permission to use their previously published work in their MD thesis, they may place a permanent embargo on their thesis at the time it is uploaded into the Yale Medicine Digital Thesis Library (see below).

Upon receiving notification that the MD thesis has been approved as meeting graduation requirements, students should upload the thesis to the Yale Medicine Digital Thesis Library.

Yale Medicine Digital Thesis Library:

Starting with the YSM class of 2002, the Cushing/Whitney Medical Library and OSR have collaborated on the Yale Medicine Digital Thesis Library (YMTDL) project, publishing the digitized full text of medical student theses as a durable product of Yale student research efforts. Digital publication of theses ensures access for all scientists to a summary of such work, provides students with a formal citation for their thesis, and demonstrates the exceptional quality of student research and student-faculty cooperation at Yale. In 2006, the digital copy became a graduation requirement. Starting in 2012, alumni of the Yale School of Medicine were invited to participate in the YMTDL project by granting scanning and hosting permission to the Cushing/Whitney Medical Library, which digitized the Library’s print copy of their thesis or dissertation.

The Office of Student Research and Yale School of Medicine require that the MD thesis be submitted to the YMTDL. This submission should be accompanied by a completed “ Yale School of Medicine Digital Thesis Depositor’s Declaration Form. ”

Submitting a thesis via the ProQuest website:

Detailed instructions on how to submit a thesis via the ProQuest website will be provided to students at the time they receive notification of formal YSM thesis approval and feedback from the Office of Student Research.

The electronic thesis submission process in ProQuest is organized into three major categories: Publishing information, About my dissertation/thesis, and Submission & payment. The system will walk you through the submission process step-by-step.

A few things to note: the ETD Administrator software is a 3rd party product that YSM licenses from ProQuest. Because this vendor is unaffiliated with Yale, OSR and Yale University Libraries do not have control over its policies or processes. The ProQuest Dissertations and Theses Global database is a subscription resource that collects dissertations and theses from multiple countries and a range of academic specialties. This collection is then made available to subscribers. When students choose to make their thesis publicly available, the full-text will appear in this database and users will be able to read, save, and download the text.

EliScholar is a digital platform for scholarly publishing provided by the Yale University Library (YUL). While it is supported by third party software, EliScholar is maintained by YUL and offers more flexibility in uploading and managing theses. The option selected for thesis release in the ETD Administrator system will apply to both ProQuest Dissertations and Theses Global and EliScholar. All theses are available to the Yale community (individuals with a NetID and password and users physically present at a library facility on campus) upon publication. A limited release of approved theses to the awarding institution’s user community is common practice.

YSM requires a Thesis Publishing Agreement Form, previously known as a Thesis Deposit Declaration Form, to be submitted in conjunction with your final thesis to ProQuest. For reference, you can find a copy of the form at this link .

We urge your participation in evaluating your experience with your thesis advisor at this Qualtrics link . The results will be kept anonymous, and any feedback to the individual faculty member will be made over a three- to four-year interval and will be a summarized statement, not involving reproduction or direct quotes from this form.

We will file these evaluations for future use by first and second year students who are looking for a project and research advisor. These evaluations have been immensely valuable to students initiating thesis projects. Thank you for your cooperation in this effort.

Contact us if you have questions or need accessibility assistance with the documents on this page.

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Writing a medical thesis: tips for post-graduate students.

Writing a Medical Thesis Tips for Post-Graduate Students

What is a medical thesis?

A medical thesis is the written work resulting from an original research in the field of Medicine, Nursing, Pharmacy, and other health and life sciences. It is submitted by the students in order to obtain a higher degree from the University.

However, keep this in mind! The purpose of submitting a medical thesis is not limited to the achievement of a doctoral or post-graduate degree. It is a medium to organize the scientific knowledge in a way to make further progress in the field.

That’s the reason why the experts in  medical thesis writing  stress on the importance of choosing the right topic for your thesis. You must be able to address a genuine problem or series of problems through your medical thesis. Choose a topic that aligns with your interest and where you can offer a fresh perspective through your research study.

Writing your medical thesis

After choosing the topic for your research study, collaborate with your supervisor to design your research study and its goal. Collect all the information and data pertaining to your research before proceeding with your clinical trials.

Now, you are ready with your research data and clinical findings. You just need to pen down your findings in your medical thesis.

That sounds easy, isn’t it?

In reality, it’s not so. But, you need not worry!  Writing a medical thesis  becomes easy and fun if you follow the given steps with competence:

1.Outline the structure of medical thesis

Prepare an outline of the thesis in accordance with the following sections:

  • Introduction: Why did you start your study?
  • Methods Used
  • Results of the study
  • Discussion of results

List the major sections and chapters in each. Do a section at a time. Assemble all the figures and tables and organise them into a logical sequence.

2.Writing a title of the thesis

The title reflects the content of your thesis. For writing a perfect thesis title:

  • Be concise and accurate. The title must neither be too long nor too short
  • Avoid unnecessary words and phrases like “Observation of” or “A study of”
  • Do not use abbreviations
  • Avoid grammatical mistakes

3.Writing an Introduction

The purpose of writing an Introduction is to provide the reader with sufficient background information on the topic and help him understand and evaluate the results of the present study, without needing to refer to the previous publications on the topic.

  • Give this background information in brief in the first paragraph
  • Include the importance of the problem and what is unknown about it in the second paragraph
  • State the purpose, hypothesis, and objective of your study in the last paragraph

Cite the research papers written on your research topic

  • Include unnecessary information other than the problem being examined
  • Include the research design, data or conclusion of your study
  • Cite well-known facts
  • Include information found in any textbook in the field

4.Writing the section of “Methods Used”

This section must be so written that the reader is able to repeat the study and validate its findings.

Write a detailed exposition about the participants in the study, what materials you used and how you analyzed the results

  • Give references but no description for established methods
  • Give a brief description and references for published but lesser known methods
  • Give detailed description of new methods citing the reasons for using them and any limitations if present
  • Include background information and results of the study
  • Refer to animals and patients as material
  • Use trade name of the drugs; instead, use their generic names
  • Use non-technical language for technical statistical terms

5.Writing your Results

Keep in mind the objective of your research while writing the “Results” section. The findings of the research can be documented in the form of:

  • Illustrative graphs

Use text to summarize small amounts of data. Do not over-use tables, figures, and graphs in your paper. Moreover, do not repeat information presented in the table or figure in the text format. Text must be a summary or highlight of the information presented in tables or figures.

6.Discussing your Results

Good medical theses have a targeted discussion keeping it focused on the topic of the research. Include:

  • Statement of the principal findings. Make it clear to show that your thesis includes new information
  • Strengths and weaknesses of your study
  • Strengths and weaknesses in relation to the other studies
  • A take-home message from your study for clinicians and policymakers
  • Any questions that are left unanswered in your study to propose new research

How to conclude your medical thesis?

The conclusion of your research study must comprise of:

  • The most important statement or remark from the observations
  • Summary of new observations, interpretations, and insights from the present study
  • How your study fills the knowledge gap in its respected field?
  • The broader implications of your work
  • How can your work be improved by future research?

However, avoid any statement that does not support your data.

With these tips, write your thesis like a pro and don’t let it delay your doctoral award!

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Investigating colonic macrophage heterogeneity in steady-state, inflammation, and resolution , social behaviour in two rat models of syngap1 haploinsufficiency , multimodal decoding of the human and mouse mesenchymal lineage in biliary fibrosis , establishing the mechanistic basis of action for novel siderophore-based antibiotics in gram-negative bacteria , planar cell polarity pathway as a master regulator of biliary morphogenesis , anatomical, biomechanical and histological evaluation of the glenoid labrum , circuitry and function of layer 1 interneurons in the medial entorhinal cortex , exploiting large-scale exome sequence data to study the genotype-phenotype relationship , characterising disease heterogeneity in crohn's disease and ulcerative colitis: leveraging longitudinal biomarker profiles , influence of glucocorticoid bioavailability on atherogenesis , manganese-enhanced magnetic resonance imaging in cardiometabolic disorders , visual experience dependent control of nmdar subunit composition and neuronal gene expression: a critical role for the glun2a c-terminal domain , using data to understand outcomes for cancer surgery in low- and middle-income countries , modulation of tissue glucocorticoid exposure by cleavage of corticosteroid binding globulin in humans , investigating the role of macrophage-epithelial cell interaction in salivary gland regeneration , determining the endometrial phenotype of women with abnormal uterine bleeding , investigating the role of microglial senescence in central nervous system injury and regeneration , characterisation of the pro-regenerative extracellular matrix in the zebrafish spinal cord , different mutations in the beta-tubulin tubb4b result in a novel spectrum of dominant-negative ciliopathies , investigating the modulators of positional identity in human neuromesodermal progenitor differentiation in vitro .

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Kasturba Medical College, Mangalore Theses and Dissertations

Theses/dissertations from 2021 2021.

“The Impact of Self-Stigma of Seeking Help and Perceived Social Support on Burnout among Clinical Psychologists” , Aavrita A

The impact of self-stigma of seeking help &percieved social support on burnout among clinical psychologists. , Aavrita .

Immediate Effects of Novel Hand Rehabilitation Board on Fine Motor Skills in Children with Cerebral Palsy. , Romita Fernandes. Abraham

"COMPARISON OF THREE SCORING CRITERIA TO ASSESS RECOVERY FROM GENERAL ANAESTHESIA IN THE POST-ANAESTHESIA CARE UNIT- A LONGITUDINAL OBSERVATIONAL STUDY " , Shagun Aggarwal

Comparative predictive validity of Alberta Infant Motor Scale and Infant Neurological International Battery in Low Birth Weight Infants- A Prospective Longitudinal Study. , Polisetti Siva Sai Anand

Antagonistic Asynchrony in Muscle Recruitment Pattern of Forward Reach Movement In Children With Cerebral Palsy. , Sanya Anklesaria

Muscle fatigue response of rotator cuff muscles in sitting and standing postures , Lisanne Aranha

Effectiveness of static weight bearing versus modified constraint induced movement therapy on improving hand function in hemiplegic cerebral palsy- A Randomized Clinical Trial. , Ruth Bavighar

How informed are our patients about generic medicines? – A study from coastal South India , Darshan BB

Morphological variants of the human spleen, a cadaveric study , Murlimanju BV

Association between cervical breast cancer and Diabtetes mellitus among women seeking health care in tertiary hospitals od south India: A cross sectional study , Pratik Kumar Chatterjee

Carcinoma Breast in among Women with Diabetes Mellitus: A Case Control Study , Pratik Kumar Chatterjee

Perception of Empathy among medical students: A cross sectional study , Pratik Kumar Chatterjee

CLINICOMYCOLOGICAL PROFILE OF DERMATOPHYTOSIS IN A TERTIARY CARE HOSPITAL IN SOUTH INDIA , Adyashree Dalai

Study of outcome of Ponseti technique of management for idiopathic clubfoot in a tertiary center in south India , Lulu Damsas

Comparative study of emotional labour &burnout on life satisfaction among school teachers across different educational settings , Meghana Dharampalan

“Comparative Study of Emotional Labor and Burnout on Life Satisfaction Among School Teachers Across Different Educational Settings” , Meghana V. Dharmapalan

“Relationship Between Sexual Fantasy, Sexual Communication, Personality Traits and Sexual Satisfaction in Married Individuals” , Rhea Dhir

Comparing the efficacy of USG guided supraclavicular brachial plexus block with or without intercostobrachial nerve block for forearm surgeries – an observational study , DIKSHA D’MELLO

Does Quality of Sitting influence Functional Mobility in Cerebral Palsy? A cross-sectional study , Kaiorisa N. Doctor

Factors effecting gait velocity in osteoarthritis knee-An observational study. , Lisha Gretal D’silva

Effect of Inspiratory Muscle Training on Pulmonary Function, Functional Capacity, Quality Of Life And Length Of Stay in individuals undergoing Cardiac Surgery , Fiona Verdine Dsouza

Relationship of Academic Resilience with Self-Efficacy, and Perceived Social Support; Among Civil Service Aspirants , Neha Eldho

EFFICACY, FEASIBILITY, AND SAFETY OF PERCUTANEOUS IMAGE-GUIDED CATHETER DRAINAGE OF THORACIC, ABDOMINAL, AND PELVIC FLUID COLLECTION , Aishwarya Gadwal

Comparison of efficacy of two different bolus doses of norepinephrine as prophylac-tic to prevent post-spinal hypotension during elective caesarean section , PRANATHI GARAPATI

Trends in Frailty and its Associated factors in Community Dwelling Elderly Indian Population during COVID-19 Pandemic- A Prospective Analytical Study , Karan Gautam

Speech Sound acquisition in some south Indian Dravidian languages: A systematic review , Jesica George

Comparison of Femoral nerve block with Dexmedetomidine and Adductor canal block with Dexmedetomidine for postoperative analgesia for Total Knee Arthroplasty . , NEHA GEORGE

Assessment Of Cardiovascular Risk Factors In Patients With Osteoarthritis Knee , Sagar Goel

Effectiveness of Intermittent Cervical Traction with and without Neural Mobilization in Discogenic Cervical Radiculopathy , Aditi Goyal

Study of maternal and cord blood vitamin B12 levels with anthropometry in term neonates born to normal and malnourished mothers: a hospital based cross sectional study , Sugapradha a. GR

Development of a Questionnaire to Determine the Intervention and Service Delivery Practices of Speech-Language Pathologists for Children with Speech Sound Disorders in India , Shaily Gupta

Relationship between Physical Activity, Objective Sleep Parameters and Circadian Rhythm in Patients with Head and Neck Cancer receiving Chemoradiotherapy- A Longitudinal Study , Rachita Gururaj

“Emotional Contagion, Perceived Stress and Coping Strategies Among Nurses” , Saumya Hariharan

Assessment of knowledge and belief about stuttering among undergraduate medical students , Anushree Harihar

Association of serum lipid levels and other systemic risk factors with retinal hard exudates in diabetic retinopathy patients. , Harshita Mukesh Hiran

Assessment of risk of Diabetes Mellitus by using Indian Diabetes Risk Score among Housekeeping staff , Ramesh Holla

“Emotional Intelligence, Self-compassion, and Life-Satisfaction In Clinical Psychologists” , Vania Jacob

UPPER-CROSSED SYNDROME AND DISABILITY IN SHOULDER ADHESIVE CAPSULITIS. , Aishwarya Jaideep

Study to assess the role of doppler ultrasound in evaluation of arteriovenous hemodialysis fistula and the complications of hemodialysis access , Ishank Jain

Relationship between burnout compassion fatigue, work environment & mindfulness in medical residents , Pranay Javeri

“Relationship Between Burnout, Compassion Fatigue, Work Environment and Mindfulness in Medical Residents” , Pranay Harichandra Javeri

“Dating Anxiety in Emerging Adults” , Jisha V. Jayaprakash

“Relationship Between Tolerance for Disagreement and Mindfulness in Married Males and Married Females” , Jahnavi Jha

Antibiotic usage and susceptibility patterns in Uncomplicated UTI in a Tertiary Hospital in South India , Christy John

Association of bed rise difficulty scale with trunk impairment and functional scales among stroke patients , Leena G. John

Is there a correlation between Pediatric Berg Balance Scale and Centre of Pressure Excursion measured through Dual Axis Static Force Plate™ to assess Balance in Children with Spastic Cerebral Palsy and Typically Developing? , Niharika Joshi

Comparison of Sensory Processing Responses in Cerebral Palsy Subtypes and Typically Developing Children (7-36 months): A Cross Sectional Study. , Archana Antony K

‘A study on the Role of Learned Helplessness, Selfefficacy and Perceived Social Support in Determining Resilience in Parents of Children with Neurodevelopmental Disorders’ , Benaisha Khurshed Katrak

A study of correlation of maternal serum zinc levels with breast milk and cord blood of late preterm neonates , Rashmi Katti

Correlation of histopathology and direct immunofluorescence findings in clinically diagnosed prurigo nodularis , Haritha K

Difference in proximal femur loading due to muscle activity during partial weight bearing and NWB standing- A cross-sectional study. , Smital Kshirsagar

Effect of Sesamol on neurobiochemical changes in diet induced (DIO) obesity model of Zebra fish (Danio rerio) , Rashmii K.S.

Importance of integration of medical ethics with undergraduate medical curriculum- Instructors and student’s perspectives. , Rashmii K.S.

Long-term potentiation (LTP): A simple yet powerful cellular process in learning and memory , Rashmii K.S.

Parkinson's Disease Overview: Alternative Potential Curcumin Treatment, Current Treatment and Prevalence Among Ethnic Groups , Rashmii K.S.

Smart brain of India vs. tricky drugs , Rashmii K.S.

The Role of Professionalism and Ethics Training: Instructor’s and Student’s perspectives in a medical College , Rashmii K.S.

Violence Against Doctors: A Qualitative Study On This Rising Predicament , Rashmii K.S.

Morphometric study of the gracilis muscle and its pedicles , Chettiar Ganesh Kumar

Comparative study of bed side tests to assess difficult airway in paediatric patients , S.Abinandha Kumar

Euphorbia thymifolia (Linn.)- A review on ethno pharmacological properties , Vasavi Kumblekar

COMPARISON OF KNOWLEDGE, ATTITUDE, AND PRACTICE TOWARDS THE USE OF SUNSCREEN IN DAILY LIFE BETWEEN FIRST -AND THIRD -YEAR MEDICAL STUDENTS , Aarushi Lall

‘Feminist Identity, Socio-cultural Attitude Towards Appearance, and Body Images issues in Emerging Adult Women’ , Sheena Lonappan

A novel approach to quantify the Dynamic Windlass Mechanism , Ishita Mahajan

METFORMIN VERSUS INSULIN IN THE MANAGEMENT OF GESTATIONAL DIABETES , Varikuti Manogna

Cognitive abilities among employed and unemployed middle-aged women – a systematic review , Aswini M

‘Emotional Intelligence, Job Satisfaction and Psychological Well-being Among Nurses’ , Chetna M

RELATIONSHIP OF COMPUTER AIDED DESIGN(CAD)-BASED PHOTOGRAMMETRY FOR FACIAL DYSFUNCTION WITH FACIAL GRADING SYSTEMS FOR BELL’S PALSY: A PROSPECTIVE OBSERVATIONAL STUDY , Ankita Mehendale

“Effect of Sensation Seeking and Anxious Traits on Suicidal Ideation Among Adults by Birth Order” , Haripriya G. M

Clinical & radiological assessment of intertrochanteric fractures treated with PFN A2 , Harish M

Effect of a home-based pulmonary rehabilitation programme on respiratory function, functional capacity, and quality of life in patients with chronic obstructive pulmonary disease , Vaibhavi Mhatre

Profiling Communication Characteristics of Individuals with Acquired Neuro-communication Disorder in a Tertiary Care Setup , Nikita Subudhi M

Relationship between weight bearing symmetry, trunk control and fear of fall amongst subjects with stroke: A cross sectional study , VIVIAN NEHAL MONIS

Lower extremity muscle recruitment pattern during sit to stand transfer in children with cerebral palsy as compared to typically developing children- a cross sectional study. , Kiran P. Nadgauda

Knowledge, attitudes and practices of Indian classical singers towards vocal healthcare , Raveena Muralidharan Nair

"Perspectives of Indian Speech Language Pathologists on Adolescent Language Assessment" , Rohana Muralidharan Nair

Effect Of Yoga On Perceived Stress And Pulmonary Function In High Stressed Postmenopausal Women , Vinodini NA

Refractory errors, blood groups & diabetes mellitus: A corrleative study in south Indian population , Vinodini NA

Comparison of Functional outcomes for displaced extra-articular distal radius fractures managed by Conservative versus Operative methods: A Prospective cohort study , Muhammed Ehsan Nazeer

COMPARATIVE STUDYOF THE EFFECTIVENESS OF VAPOCOOLANT SPRAY VERSUS EMLA®® CREAM IN REDUCING PAIN DURING INTRAVENOUS CANNULATION IN ADULT POPULATION , Sisla Nazer P

Assessment of attitude among public towards stuttering in a coastal city of Southern Karnataka , Prithvi N

"Severity assessment of acute pancreatitis using ct severity index and modified ct severity index: association with clinical outcomes and ranson’s criteria. " , GEETANJALI PARMAR

“The Effect of Culture Shock on Adjustment and Psychological Wellbeing Among College Going Students” , Akanksha Patra

‘Effect of Religiosity on Attitude Towards Euthanasia in Medical Students’ , Sumedha Pawar

Development Of A Questionnaire To Determine The Clinical Assessment Practices Of Speech-Language Pathologists For Children With Speech Sound Disorders In India , Prasila Elsa Philip

Correlation of oxidised LDL with oxidant and antioxidant enzymes in subjects with elevated LDL levels , Pooja p

Association of emotional intelligence of primigravida mothers with breastfeeding self efficacy in the early postpartum period and exclusive breastfeeding rates up to 6 months. , Priyanka Reddy p

Morphometric study of the Sartorius muscle and its vascular pedicles , M.D. Prameela

Comparison of the analgesic duration using ultrasound guided popliteal sciatic nerve block between diabetics with neuropathy and non-diabetics without neuropathy , GANESH PRASAD

Early follicular and Mid-luteal phase associated changes in Lower extremity Muscle strength , length and Agility in amateur female athletes – a Prospective Analytical study , Vishnu Priya

Assessment of mobile device based educational intervention on breastfeeding technique in multigravida mothers and its effect on early infant feeding pattern- A randomized controlled trial. , Keerthi Raj

THERMAL ULTRASOUND, MANIPULATION AND EXERCISE ON PAIN AND MOUTH OPENING IN CHRONIC TEMPOROMANDIBULAR JOINT DISORDER: A CASE REPORT , Suchita S. Rao

Correlation of Histopathology and Direct Immunofluorescence: Findings in clinically diagnosed Prurigo nodularis in a Tertiary care hospital , Haritha Reddy

EFFECT OF POSITIONING ON THE PAIN RESPONSE OF INFANTS VACCINATED WITH IPV AND PENTAVALENT (dtwp-HEPATITIS B-HEMOPHILUS INFLUENZA B) VACCINES , Sontosh Reddy

Assessment of the acceptable length of Right internal jugular central venous catheters. , Nivedhitha R

PRELEVANCE OF WORK RELATED DERMATOLOGICAL SYMPTOMS IN HEALTH CARE WORKERS IN COVID-19 ERA , Rana R

COMPARISON OF TWO ROUTINE FACIAL EXERCISE PROTCOLS FOR BELL’S PALSY- A RANDOMIZED CONTROLLED TRIAL , Stephanie Santiago

Profiling selected speech characteristics in individuals with Chronic Cough , Nawal Palakkal Sathar

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Ethical Lapses in the Medical Profession

More from our inbox:, don’t cave, columbia, a florida book oasis, balloon release ban.

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To the Editor:

Re “ Moral Dilemmas in Medical Care ” (Opinion guest essay, May 8):

It is unsettling, and dismaying, to read Dr. Carl Elliott’s account of moral lapses continuing to exist, if not thrive, in medical education. As a neurology resident in the early 1970s, I was assigned a patient who was scheduled to have psychosurgery.

He was a prisoner who had murdered a nurse in a hospital basement, and the surgery to remove part of his brain was considered by the department to be a therapeutic and even forward-looking procedure. This was despite its being widely discredited, and involving a prisoner who could not provide truly informed consent.

A fellow resident and I knew that refusing would almost certainly result in suspension or dismissal from the residency, so we anonymously contacted our local newspapers, whose reporting resulted in an overflow protest meeting, cancellation of the psychosurgery and legislative action placing conditions on the acceptance of informed consent by prisoners.

It is lamentable that even though bioethics programs are widely incorporated into medical education, moral and ethical transgressions remain a stubborn problem as part of medical structures’ groupthink.

As Richard Feynman has emphasized , doubt, uncertainty and continued questioning are the hallmarks of scientific endeavor. They need to be an integral element of medical education to better prepare young doctors for the inevitable moral challenges that lie ahead.

Robert Hausner Mill Valley, Calif.

I would like to thank Carl Elliott for exposing the “Moral Dilemmas in Medical Care.” There is a medical school culture that favors doctors as privileged persons over patients.

I can remember multiple patient interactions in medical school in which I thanked a patient for allowing me to examine them and apologized for hurting them during my exam of their painful conditions.

I was then criticized by attending physicians for apologizing to the patients. I was told, on multiple occasions, that the patient should be thanking me for the privilege of assisting in my education.

Medical training, in a medical school culture that favors the privilege of the medical staff over the rights and feelings of patients, needs to be exposed and changed.

Doug Pasto-Crosby Nashville The writer is a retired emergency room physician.

As a psychiatrist and medical ethicist, I commend Dr. Carl Elliott for calling attention to several egregious violations of medical ethics, including failure to obtain the patient’s informed consent. Dr. Elliott could have included a discussion of physician-assisted suicide and the slippery slope of eligibility for this procedure, as my colleagues and I recently discussed in Psychiatric Times .

For example, as reported in The Journal of Eating Disorders , three patients with the eating disorder anorexia nervosa were prescribed lethal medication under Colorado’s End-of-Life Options Act. Because of the near-delusional cognitive distortions present in severe anorexia nervosa, it is extremely doubtful that afflicted patients can give truly informed consent to physician-assisted suicide. Worse still, under Colorado law, such patients are not required to avail themselves of accepted treatments for anorexia nervosa before prescription of the lethal drugs.

Tragically, what Dr. Elliott calls “the culture of medicine” has become increasingly desensitized to physician-assisted suicide, nowadays touted as just another form of medical care. In the anorexia cases cited, informed consent may have been one casualty of this cultural shift.

Ronald W. Pies Lexington, Mass. The writer is on the faculty of SUNY Upstate Medical University and Tufts University School of Medicine, but the views expressed are his own.

Carl Elliot’s article on medical ethics was excellent. But it is not just in the medical profession that there exists the “subtle danger” that assimilation into an organization will teach you to no longer recognize what is horrible.

Businesses too have a culture that can “transform your sensibility.” In many industries executives check their consciences at the office door each morning. For example, they promote cigarettes; they forget they too breathe the air as they lobby against clean-air policies; they forget they too have children or grandchildren as they fight climate-friendly policies or resist gun-control measures. The list could go on.

In every organization, we need individuals to say no to policies and actions that may benefit the organization but are harmful, even destructive, to broader society.

Colin Day Ann Arbor, Mich.

Re “ Columbia’s Protests Also Bring Pressure From a Private Donor ” (front page, May 11):

Universities are meant to be institutions of higher learning, research and service to the community. They are not items on an auction block to be sold to the highest bidder.

Universities that sell off their policy platform to spoiled one-issue donors who threaten to throw a tantrum no longer deserve our respect. Grant-making foundations should not be grandstanding online. Give money, or don’t, but don’t call a news conference about it.

If Columbia caves, why should prospective students trust it as a place where they can go to become freethinkers and explore their own political conscience as they begin to contemplate the wider world and issues of social justice?

This is a real test of Columbia and its leadership. I do not envy its president, Nemat Shafik, who has few good choices and no way to make everyone happy. What she should not sell is her integrity, or the university’s. She should stand up to these selfish donors. Learn to say, “Thanks, but no thanks.”

Carl Henn Marathon, Texas

Re “ Book Bans? So Open a Bookstore ” (Arts, May 13):

Deep respect for the American novelist Lauren Groff and her husband, Clay Kallman, for opening the Lynx, their new bookstore in Gainesville, Fla. The store focuses on offering titles among the more than 5,100 books that were banned in Florida schools from July 2021 through December 2023.

To all the book clubbers and haters of bans: Order straight from the Lynx.

Fight evil. Read books.

Ted Gallagher New York

Re “ Keep a Firm Grip on Those Mickey Mouse Balloons. It’s the Law ” (front page, May 9):

Balloons are some of the deadliest ocean trash for wildlife, as mentioned in your article about Florida’s expected balloon release ban.

Plastic balloon debris poses a significant threat to marine life, often mistaken for food or becoming entangled in marine habitats, leading to devastating consequences for our fragile ocean ecosystems.

As the founder of Clean Miami Beach, an environmental conservation organization, I’m concerned about the impact of plastic pollution on Florida’s wildlife and coastal areas. Florida’s stunning beaches and diverse marine life are not only treasures to us locals but also draw millions of tourists each year.

Because of the dangers, intentional balloon releases have been banned in many cities and counties across the state. A poll released by Oceana showed that 87 percent of Florida voters support local, state and national policies that reduce single-use plastic. Gov. Ron DeSantis must waste no time in signing this important piece of legislation into law.

Our elected officials should continue to work together to address environmental issues so Floridians and tourists can enjoy our beautiful state without its being marred by plastic pollution.

Sophie Ringel Miami Beach

E. B. White is one of the most famous children’s book authors. But he should be better known for his essays.

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I was well into adulthood before I realized the co-author of my battered copy of The Elements of Style was also the author of Stuart Little and Charlotte’s Web . That’s right, the White of the revered style manual that everyone knew as “Strunk and White” also wrote children’s books…as well as some of the best essays in the English language.

If you’re of a certain age, you might well remember E. B. White’s pointers in The Elements of Style :

Place yourself in the background; write in a way that comes naturally; work from a suitable design; write with nouns and verbs; do not overwrite; do not overstate; avoid the use of qualifiers; do not affect a breezy style; use orthodox spelling; do not explain too much; avoid fancy words; do not take shortcuts at the cost of clarity; prefer the standard to the offbeat; make sure the reader knows who is speaking; do not use dialect; revise and rewrite.

That’s some good advice, much better than the terrible counsel offered on Page 76: “Avoid the elaborate, the pretentious, the coy, and the cute.” Thanks, E. B., I do what I want. ☹️

Born in 1899 in Mount Vernon, N.Y., Elwyn Brooks White attended Cornell University, where he earned the nickname “Andy.” (Weird historical fact: If your last name was White, you were automatically an Andy at Cornell, in honor of the school’s co-founder, Andrew Dickson White. There is no connection to fellow Cornell alum Andy Bernard .) After graduation, White worked as a journalist and an advertising copywriter for several years. He published his first article in The New Yorker the year it was founded, 1925.

White became a staff writer at The New Yorker in 1927, but was an early enthusiast of the work-from-home movement, initially refusing to come to the office and eventually agreeing to come in only on Thursdays. In those days, he shared a small office (“a sort of elongated closet,” he called it) with James Thurber.

His famous officemate later recalled that White had an odd a brilliant habit: When visitors were announced, he would climb out the office window and scamper down the fire escape. “He has avoided the Man in the Reception Room as he has avoided the interviewer, the photographer, the microphone, the rostrum, the literary tea, and the Stork Club,” Thurber later remembered of the chronically shy author. “His life is his own.”

In 1929, White and Thurber co-authored their first book, Is Sex Necessary? Or, Why You Feel the Way You Do . (Don’t worry: It was comic essays.) That same year, White married Katharine Angell, The New Yorker’s fiction editor from its inaugural year until 1960. She was the mother of Roger Angell , the famed essayist and baseball writer who himself became a fiction editor at The New Yorker in the 1950s.

In 1938, White and Katharine moved permanently to a farm in Maine they had purchased five years before. If you’re wondering about the inspiration for 1952’s Charlotte’s Web , look no further than White’s 1948 essay for The Atlantic, “ Death of a Pig .” (He bought the pig with the intention of fattening it for slaughter; instead, he later nursed it through a fatal illness and buried it on the farm.)

Stuart Little had been published seven years before Charlotte’s Web . Along with 1970’s The Trumpet of the Swan , these books have made White one of the nation’s best-known children’s authors. I’m sure White didn’t mind, but by all rights, he should be better known for his essays. He authored over 20 collections of such classics as “Once More to the Lake,” “The Sea and The Wind That Blow,” “The Ring of Time,” “A Slight Sound at Evening” and “Farewell, My Lovely!” Endlessly anthologized, many are also taught in writing workshops to this day.

In 1949, White published Here Is New York , a short book developed from an essay about the pros and cons of living in New York City. In a 2012 essay for America , literary editor Raymond Schroth, S.J., noted White’s juxtaposition in Here Is New York of technological terrors like nuclear bombers (the Soviet Union detonated its first atomic bomb in 1949) with the simple beauties of nature:

Grand Central Terminal has become honky tonk, the great mansions are in decline, and there is generally more tension, irritability and great speed. The subtlest change is that the city is now destructible. A single flight of planes no bigger than a flock of geese could end this island fantasy, burn the towers and crumble the bridges. But the United Nations will make this the capital of the world. The perfect target may become the perfect “demonstration of nonviolence and racial brotherhood.” A block away in an interior garden was an old willow tree. This tree, symbol of the city, White said, must survive.

“It is a battered tree, long suffering and much climbed, held together by strands of wire but beloved of those who know it,” White wrote in Here Is New York . “In a way it symbolizes the city: life under difficulties, growth against odds, sap-rise in the midst of concrete, and the steady reaching for the sun. Whenever I look at it nowadays, and feel the cold shadow of the planes, I think: ‘This must be saved, this particular thing, this very tree.’”

The tree lasted for another six decades —two more than the Cold War, in fact—before finally being chopped down in 2009.

In a 1954 review of books by White and James Michener, America literary editor Harold C. Gardiner, S.J. , said White “has one of the most distinctive styles discernible on the American literary scene.” Since even the most cursory review of Father Gardiner’s many years of commentary shows he hated almost everything, it was quite a compliment. (Later in the review, he noted that “Mr. Michener, who has done better in his other books, comes a cropper here mainly because his style is wooden, sententious and dull.”)

In 1963, White received the Presidential Medal of Freedom for his writings. Fifteen years later, he was awarded a special Pulitzer Prize for “his letters, essays, and the full body of his work.” In 2005, the composer Nico Muhly debuted a song cycle based on The Elements of Style at the New York Public Library. Among its signature moments was a tenor offering more of White’s good advice, this time in song:

Do not use a hyphen between words that can be better written as one word .

White died in 1985 at his farm in Maine. His wife Katharine had died eight years earlier. His obituary in The New York Times quoted William Shawn, the legendary editor of The New Yorker:

His literary style was as pure as any in our language. It was singular, colloquial, clear, unforced, thoroughly American and utterly beautiful. Because of his quiet influence, several generations of this country's writers write better than they might have done. He never wrote a mean or careless sentence. He was impervious to literary, intellectual and political fashion. He was ageless, and his writing was timeless.

Our poetry selection for this week is “ Another Doubting Sonnet ,” by Renee Emerson. Readers can view all of America ’s published poems here .

Also, news from the Catholic Book Club: We are reading Norwegian novelist and 2023 Nobel Prize winner Jon Fosse’s multi-volume work Septology . Click here to buy the book, and click here to sign up for our Facebook discussion group .

In this space every week, America features reviews of and literary commentary on one particular writer or group of writers (both new and old; our archives span more than a century), as well as poetry and other offerings from America Media. We hope this will give us a chance to provide you with more in-depth coverage of our literary offerings. It also allows us to alert digital subscribers to some of our online content that doesn’t make it into our newsletters.

Other Catholic Book Club columns:

The spiritual depths of Toni Morrison

What’s all the fuss about Teilhard de Chardin?

Moira Walsh and the art of a brutal movie review

​​Who’s in hell? Hans Urs von Balthasar had thoughts.

Happy reading!

James T. Keane

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James T. Keane is a senior editor at America.

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Psychopharmacology

Whistleblowers and medical fraud: a book review, a new book on the history—and price—of exposing corruption in medical research..

Updated May 14, 2024 | Reviewed by Michelle Quirk

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  • In medicine, whistleblowers face institutional denial, stonewalling, retaliation, and other kinds of reprisal.
  • They expose coercive recruitment practices, conflicts of interest, weak protocols, and missing consent.
  • In revisiting some of medicine’s worst scandals, a new book details the efforts taken to block accountability.

Source: Norton and Co.

“Nobody should indulge in the fantasy that they will be celebrated for blowing the whistle,” warns Carl Elliott in his riveting new book, The Occasional Human Sacrifice: Medical Experimentation and the Price of Saying No, published today by Norton. “It is more likely that they will be vilified, forgotten, or both.”

The more than half-dozen cases detailed in his investigation bear out that message with telling regularity. Whether from institutional denial , stonewalling, protection, retaliation, or other kinds of reprisal, whistleblowing in medicine is shown to carry a high risk of failure. Those seeking accountability are often the only ones to face any consequences, and they can be severe: demotion or job loss, hefty legal fees, unwanted notoriety, and a strong risk of being disowned by one’s coworkers.

“It's a demoralizing book,” Elliott tells me when I request an advanced copy, “but, well, that’s what the subject demanded.” It does. The scale of injury detailed in each chapter—coupled with extensive evidence from archives and local media—is as daunting as are the many efforts by institutions to deny error and responsibility.

Even more tawdry are examples where the culpable feign persecution, claiming that they are the real victim—of a witch-hunt or smear campaign. On several occasions, the fervor of denial is enough to persuade oddly incurious review boards and regulatory agencies that the malpractice is sound, even that the work merits praise and prizes (in one case, a Nobel).

Meanwhile, those driven to expose the fraud—whether of coercive recruitment practices, glaring conflicts of interest, failure to establish informed consent, or vague protocols and missing control groups—can end up fired, discredited, and rejected. “What we do essentially,” a manager concedes, “is put [the colleague] in a little boat, tow it out to sea, and cut the rope. We never think about [them] again.”

“I felt an antipathy against me,” one employee recalls after a well-considered decision to take his findings to the agency empowered to investigate them. “They feared I was opening my mouth too wide.”

Another is berated for confirming that two patients had recently died on the study protocol, a harbinger of dozens more: “Who the hell are you to question what we do around here?” A third remembers, “Everyone at work looked at me like I was a cobra. I couldn’t have been more alone if they put me in the toilet.”

While revisiting some of medicine’s worst scandals—examples include four decades of intentionally untreated syphilis in hundreds of African-American men, a hepatitis experiment on dozens of intellectually disabled children, a years-long series of deadly total body irradiation experiments involving the federal government, even a cover-up of egregious fraud at the same institute in Sweden that awards the Nobel Prize in medicine—Elliott provides nuanced portraits of each whistleblower, including their motivation and psychology.

Invaluably, Elliott ends up amplifying a larger theme of institutional cowardice in the face of well-evidenced corruption. One whistleblower marvels of his former coworkers, “It was astounding that nobody gave a damn,” even about a study associated with high rates of death. Others are baffled that so many peers and reviewers uncover the fraud but do nothing about it, asking: “How do you stand by and let these things happen?”

Atypical Antipsychotics and Forced Consent

Prefacing each example of medical malpractice is Elliott’s gripping account of his own seven-year ordeal after reporting on a research scandal at his home university, where for 11 years he had taught ethics in its medical school. In May 2003, the university’s Department of Psychiatry oversaw the study of second-generation antipsychotics that included a shockingly violent suicide . As reported by “Side Effects” in 2009 after further details were reported by a local newspaper, the patient had been enrolled in the study over the stated objections of his mother, since he was then in the midst of a full-blown episode and might pose a risk to himself or others. Elliott elaborates:

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The study in which Markingson died was funded by the pharmaceutical company AstraZeneca and designed to test its antipsychotic drug Seroquel. The study was marked by alarming red flags: conflicts of interest, financial pressures to get subjects into the study, a locked psychiatric unit where severely ill patients were targeted for recruitment. Most disturbing of all were the conditions under which Markingson was enrolled.… Not only was [he] psychotic when he signed the consent form, he was under a civil commitment order that legally required him to obey the recommendations of his psychiatrist. His mother wanted him to have nothing to do with the study. [The study leader ] enrolled Markingson anyway.

Further investigation unearths a disturbing number of malpractice cases in the same department: a nonconsensual addiction experiment on illiterate Hmong opium addicts, the injuries or deaths of 46 mentally ill patients under the care of a different faculty member. The professor leading the study in which Markingson died previously led a study on an experimental antipsychotic that, too, became associated with intense suicide ideation, previously unremarked. In that case, the patient managed to drop out of the trial, avoiding further risk of self-harm .

The reporting and investigation that Elliott felt compelled to pursue end up involving years of university stonewalling. Relations with even supportive colleagues sour. The intervention leads, eventually, to Senate hearings, an external review that faults the university’s oversight program and the passage of a new law in Minnesota meant to raise standards in medical research. But it generates no formal apology to Markingson’s mother. What she receives instead is a bill for legal fees sent by the same university that failed to sanction the forced participation of her son in a problematic clinical trial, even as it resulted in his death.

When Whistleblowing Backfires

Norton. Used with permission.

This is the type of maddening pattern that repeats throughout The Occasional Human Sacrifice . Publicly stated concerns about misconduct are shown to backfire, sometimes spectacularly, leading to the demotion and discrediting of previously valued colleagues. In the process, review boards and sponsoring departments end up sullied and compromised—silent accomplices to malpractice—even as they may spend years fighting the charges and proclaiming the exposure to be the only cardinal sin.

The brilliance of Elliott’s book lies in the lessons it draws from overlooked detail. In the infamous Tuskegee, Alabama, experiment by the U.S. Public Health Service on hundreds of poor Black men with syphilis, where the agency “used free meals and burial insurance to lure them into an experiment in which they would receive no treatment for [the] potentially deadly disease,” the detail is that “ very few employees of the health service … saw anything wrong with this .”

The experiment ran for 40 years and took another seven to bring fully to light: “The public health establishment fought [discovery] at every turn. When the study was finally exposed, the federal government resisted paying for medical treatment for the victims. Another twenty-five years passed before the government apologized.”

“I think there is a ‘there’ there that we just maybe didn’t want to see,” an investigator tells Elliott of the staggering institutional blindspots that recur throughout, especially when reputations and significant funds are at stake. Concerning efforts to shield yet another study from investigation, Elliott adds: “It wasn’t just that they were unhappy to see their dirty laundry aired in public. Many of them didn’t think the laundry was dirty.”

“The force of social conformity is especially powerful in institutions that are driven by a sense of moral purpose,” notes Yale social psychologist Irving Janis, cited in the book. “In academic health centers, that moral purpose is embedded in the dogma that medical research saves lives.”

“Since our groups’ objectives are good,” Janis continues, characterizing what the participants are said to feel, “any means we decide to use must be good.”

Elliott, C. (2024). The Occasional Human Sacrifice: Medical Experimentation and the Price of Saying No. New York: Norton.

Christopher Lane Ph.D.

Christopher Lane, Ph.D., is a Professor Emeritus of Medical Humanities at Northwestern University.

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May 2024 magazine cover

At any moment, someone’s aggravating behavior or our own bad luck can set us off on an emotional spiral that threatens to derail our entire day. Here’s how we can face our triggers with less reactivity so that we can get on with our lives.

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Joseph Epstein, conservative provocateur, tells his life story in full

In two new books, the longtime essayist and culture warrior shows off his wry observations about himself and the world

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Humorous, common-sensical, temperamentally conservative, Joseph Epstein may be the best familiar — that is casual, personal — essayist of the last half-century. Not, as he might point out, that there’s a lot of competition. Though occasionally a scourge of modern society’s errancies, Epstein sees himself as essentially a serious reader and “a hedonist of the intellect.” His writing is playful and bookish, the reflections of a wry observer alternately amused and appalled by the world’s never-ending carnival.

Now 87, Epstein has just published his autobiography, “ Never Say You’ve Had a Lucky Life: Especially if You’ve Had a Lucky Life ,” in tandem with “ Familiarity Breeds Content: New and Selected Essays .” This pair of books brings the Epstein oeuvre up to around 30 volumes of sophisticated literary entertainment. While there are some short-story collections (“The Goldin Boys,” “Fabulous Small Jews”), all the other books focus on writers, observations on American life, and topics as various as ambition, envy, snobbery, friendship, charm and gossip. For the record, let me add that I own 14 volumes of Epstein’s views and reviews and would like to own them all.

Little wonder, then, that Epstein’s idea of a good time is an afternoon spent hunched over Herodotus’s “Histories,” Marguerite Yourcenar’s “Memoirs of Hadrian” or almost anything by Henry James, with an occasional break to enjoy the latest issue of one of the magazines he subscribes to. In his younger days, there were as many as 25, and most of them probably featured Epstein’s literary journalism at one time or another. In the case of Commentary, he has been contributing pieces for more than 60 years.

As Epstein tells it, no one would have predicted this sort of intellectual life for a kid from Chicago whose main interests while growing up were sports, hanging out, smoking Lucky Strikes and sex. A lackadaisical C student, Myron Joseph Epstein placed 169th in a high school graduating class of 213. Still, he did go on to college — the University of Illinois at Urbana-Champaign — because that’s what was expected of a son from an upper-middle-class Jewish family. But Urbana-Champaign wasn’t a good fit for a jokester and slacker: As he points out, the president of his college fraternity “had all the playfulness of a member of the president’s Council of Economic Advisers.” No matter. Caught peddling stolen copies of an upcoming accounting exam for $5 a pop, Epstein was summarily expelled.

Fortunately, our lad had already applied for a transfer to the University of Chicago, to which he was admitted the next fall. Given his record, this shows a surprising laxity of standards by that distinguished institution, but for Epstein the move was life-changing. In short order, he underwent a spiritual conversion from good ol’ boy to European intellectual in the making. In the years to come, he would count the novelist Saul Bellow and the sociologist Edward Shils among his close friends, edit the American Scholar, and teach at Northwestern University. His students, he recalls, were “good at school, a skill without any necessary carry-over, like being good at pole-vaulting or playing the harmonica.”

Note the edge to that remark. While “Never Say You’ve Had a Lucky Life” is nostalgia-laden, there’s a hard nut at its center. Epstein feels utter contempt for our nation’s “radical change from a traditionally moral culture to a therapeutic one.” As he explains: “Our parents’ culture and that which came long before them was about the formation of character; the therapeutic culture was about achieving happiness. The former was about courage and honor, the latter about self-esteem and freedom from stress.” This view of America’s current ethos may come across as curmudgeonly and reductionist, but many readers — whatever their political and cultural leanings — would agree with it. Still, such comments have sometimes made their author the focus of nearly histrionic vilification.

Throughout his autobiography, this lifelong Chicagoan seems able to remember the full names of everyone he’s ever met, which suggests Epstein started keeping a journal at an early age. He forthrightly despises several older writers rather similar to himself, calling Clifton Fadiman, author of “The Lifetime Reading Plan,” pretentious, then quite cruelly comparing Mortimer J. Adler, general editor of the “Great Books of the Western World” series, with Sir William Haley, one of those deft, widely read English journalists who make all Americans feel provincial. To Epstein, “no two men were more unalike; Sir William, modest, suave, intellectually sophisticated; Mortimer vain, coarse, intellectually crude.” In effect, Fadiman and Adler are both presented as cultural snake-oil salesmen. Of course, both authors were popularizers and adept at marketing their work, but helping to enrich the intellectual lives of ordinary people doesn’t strike me as an ignoble purpose.

In his own work, Epstein regularly employs humor, bits of slang or wordplay, and brief anecdotes to keep his readers smiling. For instance, in a chapter about an editorial stint at the Encyclopaedia Britannica, Epstein relates this story about a colleague named Martin Self:

“During those days, when anti-Vietnam War protests were rife, a young woman in the office wearing a protester’s black armband, asked Martin if he were going to that afternoon’s protest march. ‘No, Naomi,’ he said, ‘afternoons such as this I generally spend at the graveside of George Santayana.’”

Learned wit, no doubt, but everything — syntax, diction, the choice of the philosopher Santayana for reverence — is just perfect.

But Epstein can be earthier, too. Another colleague “was a skirt-chaser extraordinaire," a man "you would not feel safe leaving alone with your great-grandmother.” And of himself, he declares: “I don’t for a moment wish to give the impression that I live unrelievedly on the highbrow level of culture. I live there with a great deal of relief.”

In his many essays, including the sampling in “Familiarity Breeds Content,” Epstein is also markedly “quotacious,” often citing passages from his wide reading to add authority to an argument or simply to share his pleasure in a well-turned observation. Oddly enough, such borrowed finery is largely absent from “Never Say You’ve Had a Happy Life.” One partial exception might be the unpronounceable adjective “immitigable,” which appears all too often. It means unable to be mitigated or softened, and Epstein almost certainly stole it from his friend Shils, who was fond of the word.

Despite his autobiography’s jaunty title, Epstein has seen his share of trouble. As a young man working for an anti-poverty program in Little Rock, he married a waitress after she became pregnant with his child. When they separated a decade later, he found himself with four sons to care for — two from her previous marriage, two from theirs. Burt, the youngest, lost an eye in an accident while a toddler, couldn’t keep a job, fathered a child out of wedlock and eventually died of an opioid overdose at 28. Initially hesitant, Epstein came to adore Burt’s daughter, Annabelle, as did his second wife, Barbara, whom he married when they were both just past 40.

Some pages of “Never Say You’ve Had a Lucky Life” will be familiar to inveterate readers of Epstein’s literary journalism, all of which carries a strong first-person vibe. Not surprisingly, however, the recycled anecdotage feels less sharp or witty the second time around. But overall, this look back over a long life is consistently entertaining, certainly more page-turner than page-stopper. To enjoy Epstein at his very best, though, you should seek out his earlier essay collections such as “The Middle of My Tether,” “Partial Payments” and “A Line Out for a Walk.” Whether he writes about napping or name-dropping or a neglected writer such as Somerset Maugham, his real subject is always, at heart, the wonder and strangeness of human nature.

Never Say You’ve Had a Lucky Life

Especially if You’ve Had a Lucky Life

By Joseph Epstein

Free Press. 304 pp. $29.99

Familiarity Breeds Content

New and Selected Essays

Simon & Schuster. 464 pp. $20.99

We are a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for us to earn fees by linking to Amazon.com and affiliated sites.

medical thesis book

StarTribune

University of minnesota professor's book investigates shocking medical research abuse.

Movies such as "Erin Brockovich" depict whistleblowers as heroes who undergo tough times before earning the satisfaction that they've benefited humanity. University of Minnesota philosophy professor Carl Elliott says that's not how it usually goes down.

Elliott, whose book "The Occasional Human Sacrifice" is out next week, knows from experience. Alerted by a 2008 series of articles in the Pioneer Press, written by Paul Tosto and Jeremy Olson (now a Star Tribune reporter), he and others investigated after the suicide of Dan Markingson, a mentally ill man who was part of a U of M study of a powerful drug. That began a frustrating quest for justice, not least for Mary Weiss, Markingson's mother, that affected relationships with colleagues. (An external review eventually acknowledged flaws in the U's oversight program.)

In his book, Elliott reflects on a youthful situation in which he failed to do the right thing and writes that he wonders now, "what I feel proud of and what I regret, the different choices I might have made, how my life might have gone if I had decided not to get involved. It has helped to talk to others who have gone through similar ordeals."

Reflecting on the experience led Elliott, 62, to seek other whistleblowers, some as far away as Sweden and New Zealand. What he found is that most were unsatisfied with the results of their labors and that some regretted what they'd tried to do.

We spoke with the Minneapolis man about his book, subtitled "Medical Experimentation and the Price of Saying No," and how whistleblowers often step into trouble they can't imagine (the interview has been edited):

Q: You write about the frustration of whistleblowing. But one case you discuss is the Tuskegee Syphilis Study, whose test subjects were unaware they were receiving no treatment. They eventually were compensated. Surely those whistleblowers were successful?

A: If any of the stories in the book had a lasting impact, it's that one. But it took a long time [four decades]. The really interesting thing to me about Tuskegee is the way it is taught in medical schools, which put a much more optimistic, positive spin on it than it deserves. The researchers responsible for it were never punished. In fact, they were honored. Many of them went to their graves convinced that they had done nothing wrong.

Q: But it has resulted in reform?

A: Yes, it has more than any of the other scandals I wrote about — or didn't write about — to do with the current regulatory regime, which is flawed but better than it was before Tuskegee.

Q : Many whistleblowers you met left the organizations on whom they blew the whistle. Did you think about leaving the U?

A: I probably should have. I didn't feel as if I could leave or wanted to leave while the Markingson case was still alive because it would have felt like giving up. Afterwards, you become so contaminated with the experience of being a whistleblower or dissenter that it makes it difficult to leave. You become toxic. No one wants to be around you. This is what John Pesando [a former researcher at Seattle's Fred Hutchinson Cancer Research Center who attempted to expose alleged abuses of patients there] says: "Once you blow the whistle, everybody is a little wary of you because they think, 'When are you going to blow the whistle in my direction?' "

The Occasional Human Sacrifice

Q: Would you do it again?

A: I probably would. I don't think I'd do it in the same way. I do feel as if I have learned something from the experience and from talking to other people.

Q: Comparing the cases in the book, it seems like a group of whistleblowers has a better chance at success than individuals?

A: Doing it alone is a recipe for disaster, for a kind of self-immolation. When I talked to Tom Devine at the Government Accountability Project — he does whistleblower law — he said that when a potential whistleblower comes to him, the first thing he tells them is, "Don't do it. Going public will ruin your life. If there's any way to get the information out without making yourself a public figure, do it."

Q: Were there any surprises in talking to whistleblowers?

A: I not only admired the people but actually liked spending time around them, really enjoyed getting to know them. If you talk to reporters — and I understand this — you will often hear that whistleblowers are a uniquely prickly, difficult, moralistic type of personality, that it requires this sort of personality to blow the whistle. I didn't find that at all. Some of these people were extraordinarily gentle, kind people. Even the ones who had a contrarian streak were very funny.

Q: How do you think the book will be received at the University of Minnesota?

A: Part of what happened as a result of that entire experience is my move from the medical school to the philosophy department. I don't have a lot of reason to go back over to that [medical] part of campus much anymore. Which has made my life easier. But I'm a little nervous about how it's going to go across. We'll see.

The Occasional Human Sacrifice

By: Carl Elliott.

Publisher: Norton, 339 pages, $29.99.

Interim books editor Chris Hewitt previously worked at the Pioneer Press in St. Paul, where he wrote about movies and theater.

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Lost in the Crowd: The Hidden Biases of Medical Fundraising

A new book takes on the spread—and the inequity—of health care crowdfunding..

medical thesis book

Julia Métraux

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Mother Jones; Marc Studer

More than 100 million Americans have medical debt , with half owing more than $2,000 ; disabled people are twice as likely to have it than those without disabilities. Annually, around half a million Americans are pushed into bankruptcy by health care costs. That’s understandably made medical fundraising through websites like GoFundMe appealing, with Americans seeking a combined $10 billion from 2010 to 2018 for health expenses. But publicly asking for financial support can also be a hindrance, affecting how crowdfunders are seen and treated by the wider public—even in a country where most are acutely aware of how health insurance is tied to jobs, and how insurers can fight not to cover many procedures and medications. 

Between 2016 and 2020, only 12 percent of United States–based GoFundMe medical fundraising campaigns met their goals, according to a 2022 study . More than that, 16 percent of campaigns received no donations at all. One of the study’s authors, University of Washington professor Nora Kenworthy, has taken a dive into the landscape of US medical fundraising in a new book, Crowded Out: The True Costs of Crowdfunding Healthcare . 

Kenworthy talked to Mother Jones about how the US private health insurance model fuels medical debt, biases that shape who people consider worthy of donations, and what medical fundraising could look like in the future—even if Congress did listen to its constituents and pass legislation enacting a more socialized healthcare system.

How has the American private insurance model contributed to the rise of medical fundraising sites like GoFundMe? 

Crowdfunding for healthcare expenses exists in lots of parts of the world—there are places like the UK and Canada, that have better health systems than we do, where people still rely on crowdfunding for a lot of uncovered healthcare and expenses associated with [it], like child care, that are still hard to pay for. But in the United States, we have a tremendous amount of crowdfunding. That seems to really arise from either things that are not covered by insurance, are covered inadequately, out-of-pocket costs that are incredibly high, or from people who are not insured, or underinsured , when they experience illness or accidents.

We live in a very capitalistic country. How does that shape people’s feelings about their own medical debt, asking for help with it, and contributing to other people’s medical expenses? Is it a source of shame, or has it been normalized?

Some of the kinds of social norms that really are deeply rooted in the United States both push people towards crowdfunding and also make it a really difficult thing for people who most need it to use successfully. We have a very extreme idea of individualism, like, “If you can’t fix it, you’re kind of on your own.” Or that the person with the most merit should win out, even when a lot of the ways that we measure merit are very much linked to privilege and racial identity and class identity and things like that. I write about the way that all these play out in the marketplace of crowdfunding, and get projected onto people’s crowdfunding campaigns.

Feelings of shame, particularly about having to start a campaign for yourself,  are exceedingly common. In interviews, I’ve also talked with people about the very acute shame that they felt in terms of having to ask for help. On the other hand, starting campaigns for other people is seen as less shameful. If someone starts a campaign for you, then that taps more into this idea of wanting to help each other, and we are also a very charitable society. That is also a result of our very capitalist and neoliberal systems: we rely a lot on each other in order to meet basic needs because so many of us are made vulnerable by these economic systems.

As you note in your book, white people’s medical campaigns tend to go viral more often than people of color’s. Can you speak to that? 

It’s important to say that the top level of racism that’s operating here is really structural racism, and the racial wealth gap, which is enormous in the United States. The way that that comes into play is that campaigns started by or on behalf of people of color, but particularly Black people, tend to do less well than campaigns for other people. There’s also an interpersonal racism and racial bias element that is playing out here, particularly with campaigns that go viral or get lots of exposure. That’s the kind of internalized biases and overt racism that we might bring to the way that we regard and read and look at campaigns that can translate as people viewing campaigns with more suspicion, more tendency to think about them as fraudulent, or more likely to blame the person who’s in need.

We see that especially with viral campaigns. I did a research project with some amazing researchers, Aaron Davis and Shauna Elbers Carlisle. What we looked at the top most viral medical campaigns in GoFundMe’s history, and so that was about 900 campaigns that had raised over $100,000. In that group of 900, we found only five were on behalf of Black women, and of those five, two had been started by white people. That, to us, speaks to these incredibly huge disparities that are happening at that more viral level of campaigns, and how people’s campaigns are being treated very differently by the crowd.

Genetics, environmental exposure, and poverty  can all contribute to the development of chronic health conditions. Yet, it can be harder to fundraise for conditions where some people blame the patient, like those who have Type II Diabetes. How does that shape crowdfunding efforts?

The really large structural factors—the neighborhood you live in, or how much money you have, or the air around you—shape the the likelihood of your becoming ill over your lifetime. Particularly when it comes to chronic health conditions, whether that’s diabetes, or congestive heart disease, or cancer; these chronic conditions are very much shaped by big factors that are out of our control. When we’re crowdfunding, we’re often looking for the solvable problem, right? For an individual, [that means] “If I can just give you this one thing, then you’ll be okay.” That’s really hard to deal with in chronic conditions.

I talked to a lot of people with diabetes, both Type I and Type II, who are reliant on insulin to survive. It’s really hard to crowdfund for insulin every month. Even when we know that the cost of insulin is absurdly high, and we understand that people need it, and if they don’t get it, they’re truly not going to survive. It’s really hard for people to find ways to use crowdfunding to solve those kinds of ongoing chronic issues. People talk to me about exactly what you’re describing: feeling blamed for their conditions, and feeling like they’re being judged by the crowd for what has happened to them. We see crowdfunding reinforcing and amplifying, and almost kind of fueling, these individual-level judgments of who’s deserving and who’s not. 

Legislation like Medicare for All could reduce further medical debt—but would it get rid of the need for medical fundraising? Where could we still see it?

What we think of as a universal health coverage system not only reduces future medical debt, but could also reduce the amount that people have to pay for certain things like insulin. A more universal system can protect people better in those periods of vulnerability. But we know that illness, particularly acute or severe illness episodes, requires lots of different kinds of social support. There are things that even very well-funded universal health systems do not cover, whether that’s experimental treatments, childcare, or perhaps specialized foods that you might be forced to take. I don’t think we should think of all crowdfunding as bad. It has the potential to meet some important needs that fall outside of formal systems.

At the same time, I think we need to remain aware of the ways that crowdfunding in its current form in the US is actually undermining the efforts that are being made to move towards more universal healthcare systems, because it’s reinforcing these ideas that not everyone deserves the same thing. That we’re all individuals, and we’re on our own when we get sick, or the idea that a marketplace mentality can be the best option for fixing these kinds of societal challenges.

All of those ideas really run completely counter to the moral ideas that undergird a more universal medical coverage system. Medicare for All is based on the idea that when people are sick, they deserve help, regardless of how good a person they are, what the color of their skin is, or how much they make. It’s the idea that we have a safety net that actually catches everyone. And that idea is just not there in crowdfunding. Crowdfunding is really kind of undermining our commitment to some of these more universal ways of supporting each other.

This interview has been lightly edited for length and clarity.

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  • Indian J Anaesth
  • v.66(1); 2022 Jan

Dissertation writing in post graduate medical education

Department of Anaesthesiology, Dr. B R Ambedkar Medical College, Bengaluru, Karnataka, India

Mridul M Panditrao

1 Department of Anaesthesiology and Intensive Care, Adesh Institute of Medical Sciences and Research (AIMSR), Bathinda, Punjab, India

2 Department of Anaesthesiology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India

Sukhminder Jit Singh Bajwa

3 Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Patiala, Punjab, India

Nishant Sahay

4 Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India

Thrivikrama Padur Tantry

5 Department of Anaesthesiology, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, Karnataka, India

Associated Data

A dissertation is a practical exercise that educates students about basics of research methodology, promotes scientific writing and encourages critical thinking. The National Medical Commission (India) regulations make assessment of a dissertation by a minimum of three examiners mandatory. The candidate can appear for the final examination only after acceptance of the dissertation. An important role in a dissertation is that of the guide who has to guide his protégés through the process. This manuscript aims to assist students and guides on the basics of conduct of a dissertation and writing the dissertation. For students who will ultimately become researchers, a dissertation serves as an early exercise. Even for people who may never do research after their degree, a dissertation will help them discern the merits of new treatment options available in literature for the benefit of their patients.

INTRODUCTION

The zenith of clinical residency is the completion of the Master's Dissertation, a document formulating the result of research conducted by the student under the guidance of a guide and presenting and publishing the research work. Writing a proper dissertation is most important to present the research findings in an acceptable format. It is also reviewed by the examiners to determine a part of the criteria for the candidate to pass the Masters’ Degree Examination.

The predominant role in a dissertation is that of the guide who has to mentor his protégés through the process by educating them on research methodology, by: (i) identifying a pertinent and topical research question, (ii) formulating the “type” of study and the study design, (iii) selecting the sample population, (iv) collecting and collating the research data accurately, (v) analysing the data, (vi) concluding the research by distilling the outcome, and last but not the least (vii) make the findings known by publication in an acceptable, peer-reviewed journal.[ 1 ] The co-guide could be a co-investigator from another department related to the study topic, and she/he will play an equivalent role in guiding the student.

Research is a creative and systematic work undertaken to increase the stock of knowledge.[ 2 ] This work, known as a study may be broadly classified into two groups in a clinical setting:

  • Trials: Here the researcher intervenes to either prevent a disease or to treat it.
  • Observational studies: Wherein the investigator makes no active intervention and merely observes the patients or subjects allocated the treatment based on clinical decisions.[ 3 ]

The research which is described in a dissertation needs to be presented under the following headings: Introduction, Aim of the Study, Description of devices if any or pharmacology of drugs, Review of Literature, Material and Methods, Observations and Results, Discussion, Conclusions, Limitations of the study, Bibliography, Proforma, Master chart. Some necessary certificates from the guide and the institute are a requirement in certain universities. The students often add an acknowledgement page before the details of their dissertation proper. It is their expression of gratitude to all of those who they feel have been directly or indirectly helpful in conduct of the study, data analysis, and finally construction of the dissertation.

Framing the research question (RQ)

It is the duty of the teacher to suggest suitable research topics to the residents, based on resources available, feasibility and ease of conduct at the centre. Using the FINER criteria, the acronym for feasibility, topical interest, novelty, ethicality and relevance would be an excellent way to create a correct RQ.[ 4 ]

The PICOT method which describes the patient, intervention, comparison, outcome and time, would help us narrow down to a specific and well-formulated RQ.[ 5 , 6 ] A good RQ leads to the derivation of a research hypothesis, which is an assumption or prediction of the outcome that will be tested by the research. The research topic could be chosen from among the routine clinical work regarding clinical management, use of drugs e.g., vasopressors to prevent hypotension or equipment such as high flow nasal oxygen to avoid ventilation.

Review of literature

To gather this information may be a difficult task for a fresh trainee however, a good review of the available literature is a tool to identify and narrow down a good RQ and generate a hypothesis. Literature sources could be primary (clinical trials, case reports), secondary (reviews, meta-analyses) or tertiary (e.g., reference books, compilations). Methods of searching literature could be manual (journals) or electronic (online databases), by looking up references or listed citations in existing articles. Electronic database searches are made through the various search engines available online e.g., scholar.google.com, National Library of Medicine (NLM) website, clinical key app and many more. Advanced searches options may help narrow down the search results to those that are relevant for the student. This could be based on synthesising keywords from the RQ, or by searching for phrases, Boolean operators, or utilising filters.

After choosing the topic, an apt and accurate title has to be chosen. This should be guided by the use of Medical Subject Headings (MeSH) terminology from the NLM, which is used for indexing, cataloguing, and searching of biomedical and health-related information.[ 7 ] The dissertation requires a detailed title which may include the objective of the study, key words and even the PICOT components. One may add the study design in the title e.g. “a randomised cross over study” or “an observational analytical study” etc.

Aim and the objectives

The Aims and the Objectives of the research study have to be listed clearly, before initiating the study.[ 8 ] “Gaps” or deficiencies in existing knowledge should be clearly cited. The Aim by definition is a statement of the expected outcome, while the Objectives (which might be further classed into primary and secondary based on importance) should be specific, measurable, achievable, realistic or relevant, time-bound and challenging; in short, “SMART!” To simplify, the aim is a statement of intent, in terms of what we hope to achieve at the end of the project. Objectives are specific, positive statements of measurable outcomes, and are a list of steps that will be taken to achieve the outcome.[ 9 ] Aim of a dissertation, for example, could be to know which of two nerve block techniques is better. To realise this aim, comparing the duration of postoperative analgesia after administration of the block by any measurable criteria, could be an objective, such as the time to use of first rescue analgesic drug. Similarly, total postoperative analgesic drug consumption may form a secondary outcome variable as it is also measurable. These will generate data that may be used for analysis to realise the main aim of the study.

Inclusion and exclusions

The important aspect to consider after detailing when and how the objectives will be measured is documenting the eligibility criteria for inclusion of participants. The exclusion criteria must be from among the included population/patients only. e.g., If only American Society of Anesthesiologists (ASA) I and II are included, then ASA III and IV cannot be considered as exclusion criteria, since they were never a part of the study. The protocol must also delineate the setting of the study, locations where data would be collected, and specify duration of conduct of the dissertation. A written informed consent after explaining the aim, objectives and methodology of the study is legally mandatory before embarking upon any human study. The study should explicitly clarify whether it is a retrospective or a prospective study, where the study is conducted and the duration of the study.

Sample size: The sample subjects in the study should be representative of the population upon whom the inference has to be drawn. Sampling is the process of selecting a group of representative people from a larger population and subjecting them for the research.[ 10 ] The sample size represents a number, beyond which the addition of population is unlikely to change the conclusion of the study. The sample size is calculated taking into consideration the primary outcome criteria, confidence interval (CI), power of the study, and the effect size the researcher wishes to observe in the primary objective of the study. Hence a typical sample size statement can be - “Assuming a duration of analgesia of 150 min and standard deviation (SD) of 15 min in first group, keeping power at 80% and CIs at 95% (alpha error at 0.05), a sample of 26 patients would be required to detect a minimum difference (effect size) of 30% in the duration of analgesia between the two groups. Information regarding the different sampling methods and sample size calculations may be found in the Supplementary file 1 .

Any one research question may be answered using a number of research designs.[ 11 ] Research designs are often described as either observational or experimental. The various research designs may be depicted graphically as shown in Figure 1 .

An external file that holds a picture, illustration, etc.
Object name is IJA-66-34-g001.jpg

Graphical description of available research designs

The observational studies lack “the three cornerstones of experimentation” – controls, randomisation, and replication. In an experimental study on the other hand, in order to assess the effect of treatment intervention on a participant, it is important to compare it with subjects similar to each other but who have not been given the studied treatment. This group, also called the control group, may help distinguish the effect of the chosen intervention on outcomes from effects caused by other factors, such as the natural history of disease, placebo effects, or observer or patient expectations.

All the proposed dissertations must be submitted to the scientific committee for any suggestion regarding the correct methodology to be followed, before seeking ethical committee approval.

Ethical considerations

Ethical concerns are an important part of the research project, right from selection of the topic to the dissertation writing. It must be remembered, that the purpose of a dissertation given to a post-graduate student is to guide him/her through the process by educating them on the very basics of research methodology. It is therefore not imperative that the protégés undertake a complicated or risky project. If research involves human or animal subjects, drugs or procedures, research ethics guidelines as well as drug control approvals have to be obtained before tabling the proposal to the Institutional Ethics Committee (IEC). The roles, responsibilities and composition of the Ethics Committee has been specified by the Directorate General of Health Services, Government of India. Documented approval of the Ethics committee is mandatory before any subject can be enroled for any dissertation in India. Even retrospective studies require approval from the IEC. Details of this document is available at: https://cdsco.gov.in/opencms/resources/UploadCDSCOWeb/2018/UploadEthicsRegistration/Applmhrcrr.pdf .

The candidate and the guide are called to present their proposal before the committee. The ethical implications, risks and management, subjects’ rights and responsibilities, informed consent, monetary aspects, the research and analysis methods are all discussed. The patient safety is a topmost priority and any doubts of the ethical committee members should be explained in medically layman's terms. The dissertation topics should be listed as “Academic clinical trials” and must involve only those drugs which are already approved by the Drugs Controller General of India. More commonly, the Committee suggests rectifications, and then the researchers have to resubmit the modified proposal after incorporating the suggestions, at the next sitting of the committee or seek online approval, as required. At the conclusion of the research project, the ethics committee has to be updated with the findings and conclusions, as well as when it is submitted for publication. Any deviation from the approved timeline, as well as the research parameters has to be brought to the attention of the IEC immediately, and re-approval sought.

Clinical trial registration

Clinical Trial Registry of India (CTRI) is a free online searchable system for prospective registration of all clinical studies conducted in India. It is owned and managed by the National Institute of Medical Statistics, a division of Indian Council of Medical Research, Government of India. Registration of clinical trials will ensure transparency, accountability and accessibility of trials and their results to all potential beneficiaries.

After the dissertation proposal is passed by the scientific committee and IEC, it may be submitted for approval of trial registration to the CTRI. The student has to create a login at the CTRI website, and submit all the required data with the help of the guides. After submission, CTRI may ask for corrections, clarifications or changes. Subject enrolment and the actual trial should begin only after the CTRI approval.

Randomisation

In an experimental study design, the method of randomisation gives every subject an equal chance to get selected in any group by preventing bias. Primarily, three basic types employed in post-graduate medical dissertations are simple randomisation, block randomisation and stratified randomisation. Simple randomisation is based upon a single sequence of random assignments such as flipping a coin, rolling of dice (above 3 or below 3), shuffling of cards (odd or even) to allocate into two groups. Some students use a random number table found in books or use computer-generated random numbers. There are many random number generators, randomisation programs as well as randomisation services available online too. ( https://www-users.york.ac.uk/~mb55/guide/randsery.htm ).

There are many applications which generate random number sequences and a research student may use such computer-generated random numbers [ Figure 2 ]. Simple randomisation has higher chances of unequal distribution into the two groups, especially when sample sizes are low (<100) and thus block randomisation may be preferred. Details of how to do randomisation along with methods of allocation concealment may be found in Supplementary file 2 .

An external file that holds a picture, illustration, etc.
Object name is IJA-66-34-g002.jpg

Figure depicting how to do block randomisation using online resources. (a) generation of a random list (b) transfer of the list to an MS excel file

Allocation concealment

If it is important in a study to generate a random sequence of intervention, it is also important for this sequence to be concealed from all stake-holders to prevent any scope of bias.[ 12 ] Allocation concealment refers to the technique used to implement a random sequence for allocation of intervention, and not to generate it.[ 13 ] In an Indian post-graduate dissertation, the sequentially numbered, opaque, sealed envelopes (SNOSE) technique is commonly used [ Supplementary file 2 ].

To minimise the chances of differential treatment allocation or assessments of outcomes, it is important to blind as many individuals as possible in the trial. Blinding is not an all-or-none phenomenon. Thus, it is very desirable to explicitly state in the dissertation, which individuals were blinded, how they achieved blinding and whether they tested the success of blinding.

Commonly used terms for blinding are

  • Single blinding: Masks the participants from knowing which intervention has been given.
  • Double blinding: Blinds both the participants as well as researchers to the treatment allocation.
  • Triple blinding: By withholding allocation information from the subjects, researchers, as well as data analysts. The specific roles of researchers involved in randomisation, allocation concealment and blinding should be stated clearly in the dissertation.

Data which can be measured as numbers are called quantitative data [ Table 1 ]. Studies which emphasise objective measurements to generate numerical data and then apply statistical and mathematical analysis constitute quantitative research. Qualitative research on the other hand focuses on understanding people's beliefs, experiences, attitudes, behaviours and thus these generate non-numerical data called qualitative data, also known as categorical data, descriptive data or frequency counts. Importance of differentiating data into qualitative and quantitative lies in the fact that statistical analysis as well as the graphical representation may be very different.

Data collection types

In order to obtain data from the outcome variable for the purpose of analysis, we need to design a study which would give us the most valid information. A valid data or measurement tool, is the degree to which the tool measures what it claims to measure. For example, appearance of end tidal carbon dioxide waveform is a more valid measurement to assess correct endotracheal tube placement than auscultation of breath sounds on chest inflation.

The compilation of all data in a ‘Master Chart’ is a necessary step for planning, facilitating and appropriate preparation and processing of the data for analysis. It is a complete set of raw research data arranged in a systematic manner forming a well-structured and formatted, computable data matrix/database of the research to facilitate data analysis. The master chart is prepared as a Microsoft Excel sheet with the appropriate number of columns depicting the variable parameters for each individual subjects/respondents enlisted in the rows.

Statistical analysis

The detailed statistical methodology applied to analyse the data must be stated in the text under the subheading of statistical analysis in the Methods section. The statistician should be involved in the study during the initial planning stage itself. Following four steps have to be addressed while planning, performing and text writing of the statistical analysis part in this section.

Step 1. How many study groups are present? Whether analysis is for an unpaired or paired situation? Whether the recorded data contains repeated measurements? Unpaired or paired situations decide again on the choice of a test. The latter describes before and after situations for collected data (e.g. Heart rate data ‘before’ and ‘after’ spinal anaesthesia for a single group). Further, data should be checked to find out whether they are from repeated measurements (e.g., Mean blood pressure at 0, 1 st , 2 nd , 5 th , 10 th minutes and so on) for a group. Different types of data are commonly encountered in a dissertation [ Supplementary file 3A ].

Step 2. Does the data follow a normal distribution?[ 14 ]

Each study group as well as every parameter has to be checked for distribution analysis. This step will confirm whether the data of a particular group is normally distributed (parametric data) or does not follow the normal distribution (non-parametric data); subsequent statistical test selection mainly depends on the results of the distribution analysis. For example, one may choose the Student's’ test instead of the ‘Mann-Whitney U’ for non-parametric data, which may be incorrect. Each study group as well as every parameter has to be checked for distribution analysis [ Supplementary File 3B ].

Step 3. Calculation of measures of central tendency and measures of variability.

Measures of central tendency mainly include mean, median and mode whereas measures of variability include range, interquartile range (IQR), SD or variance not standard error of mean. Depending on Step 2 findings, one needs to make the appropriate choice. Mean and SD/variance are more often for normally distributed and median with IQR are the best measure for not normal (skewed) distribution. Proportions are used to describe the data whenever the sample size is ≥100. For a small sample size, especially when it is approximately 25-30, describe the data as 5/25 instead of 20%. Software used for statistical analysis automatically calculates the listed step 3 measures and thus makes the job easy.

Step 4. Which statistical test do I choose for necessary analysis?

Choosing a particular test [ Figure 3 ] is based on orderly placed questions which are addressed in the dissertation.[ 15 ]

An external file that holds a picture, illustration, etc.
Object name is IJA-66-34-g003.jpg

Chosing a statistical test, (a). to find a difference between the groups of unpaired situations, (b). to find a difference between the groups of paired situations, (c). to find any association between the variables, (d). to find any agreement between the assessment techniques. ANOVA: Analysis of Variance. Reproduced with permission from Editor of Indian Journal of Ophthalmology, and the author, Dr Barun Nayak[ 15 ]

  • Is there a difference between the groups of unpaired situations?
  • Is there a difference between the groups of paired situations?
  • Is there any association between the variables?
  • Is there any agreement between the assessment techniques?

Perform necessary analysis using user-friendly software such as GraphPad Prism, Minitab or MedCalc,etc. Once the analysis is complete, appropriate writing in the text form is equally essential. Specific test names used to examine each part of the results have to be described. Simple listing of series of tests should not be done. A typical write-up can be seen in the subsequent sections of the supplementary files [Supplementary files 3C – E ]. One needs to state the level of significance and software details also.

Role of a statistician in dissertation and data analysis

Involving a statistician before planning a study design, prior to data collection, after data have been collected, and while data are analysed is desirable when conducting a dissertation. On the contrary, it is also true that self-learning of statistical analysis reduces the need for statisticians’ help and will improve the quality of research. A statistician is best compared to a mechanic of a car which we drive; he knows each element of the car, but it is we who have to drive it. Sometimes the statisticians may not be available for a student in an institute. Self-learning software tools, user-friendly statistical software for basic statistical analysis thus gain importance for students as well as guides. The statistician will design processes for data collection, gather numerical data, collect, analyse, and interpret data, identify the trends and relationships in data, perform statistical analysis and its interpretation, and finally assist in final conclusion writing.

Results are an important component of the dissertation and should follow clearly from the study objectives. Results (sometimes described as observations that are made by the researcher) should be presented after correct analysis of data, in an appropriate combination of text, charts, tables, graphs or diagrams. Decision has to be taken on each outcome; which outcome has to be presented in what format, at the beginning of writing itself. These should be statistically interpreted, but statistics should not surpass the dissertation results. The observations should always be described accurately and with factual or realistic values in results section, but should not be interpreted in the results section.

While writing, classification and reporting of the Results has to be done under five section paragraphs- population data, data distribution analysis, results of the primary outcome, results of secondary outcomes, any additional observations made such as a rare adverse event or a side effect (intended or unintended) or of any additional analysis that may have been done, such as subgroup analysis.

At each level, one may either encounter qualitative (n/N and %) or quantitative data (mean [SD], median [IQR] and so on.

In the first paragraph of Results while describing the population data, one has to write about included and excluded patients. One needs to cite the Consolidated Standards of Reporting Trials (CONSORT) flow chart to the text, at this stage. Subsequently, highlighting of age, sex, height, body mass index (BMI) and other study characteristics referring to the first table of ‘patients data’ should be considered. It is not desirable to detail all values and their comparison P values in the text again in population data as long as they are presented in a cited table. An example of this pattern can be seen in Supplementary file 3D .

In the second paragraph, one needs to explain how the data is distributed. It should be noted that, this is not a comparison between the study groups but represents data distribution for the individual study groups (Group A or Group B, separately)[ Supplementary file 3E ].

In the subsequent paragraph of Results , focused writing on results of the primary outcomes is very important. It should be attempted to mention most of the data outputs related to the primary outcomes as the study is concluded based on the results of this outcome analysis. The measures of central tendency and dispersion (Mean or median and SD or IQR etc., respectively), alongside the CIs, sample number and P values need to be mentioned. It should be noted that the CIs can be for the mean as well as for the mean difference and should not be interchanged. An example of this pattern can be seen in Supplementary file 3F .

A large number of the dissertations are guided for single primary outcome analysis, and also the results of multiple secondary outcomes are needed to be written. The primary outcome should be presented in detail, and secondary outcomes can be presented in tables or graphs only. This will help in avoiding a possible evaluator's fatigue. An example of this pattern can be seen in Supplementary file 3G .

In the last paragraph of the Results, mention any additional observations, such as a rare adverse event or side effect or describe the unexpected results. The results of any additional analysis (subgroup analysis) then need to be described too. An example of this pattern can be seen in Supplementary file 3H .

The most common error observed in the Results text is duplication of the data and analytical outputs. While using the text for summarising the results, at each level, it should not be forgotten to cite the table or graph but the information presented in a table should not be repeated in the text. Further, results should not be given to a greater degree of accuracy than that of the measurement. For example, mean (SD) age need to be presented as 34.5 (11.3) years instead of 34.5634 (11.349). The latter does not carry any additional information and is unnecessary. The actual P values need to be mentioned. The P value should not be simply stated as ‘ P < 0.05’; P value should be written with the actual numbers, such as ‘ P = 0.021’. The symbol ‘<’ should be used only when actual P value is <0.001 or <0.0001. One should try avoiding % calculations for a small sample especially when n < 100. The sample size calculation is a part of the methodology and should not be mentioned in the Results section.

The use of tables will help present actual data values especially when in large numbers. The data and their relationships can be easily understood by an appropriate table and one should avoid overwriting of results in the text format. All values of sample size, central tendency, dispersions, CIs and P value are to be presented in appropriate columns and rows. Preparing a dummy table for all outcomes on a rough paper before proceeding to Microsoft Excel may be contemplated. Appropriate title heading (e.g., Table 1 . Study Characteristics), Column Headings (e.g., Parameter studied, P values) should be presented. A footnote should be added whenever necessary. For outputs, where statistically significant P values are recorded, the same should be highlighted using an asterisk (*) symbol and the same *symbol should be cited in the footnote describing its value (e.g., * P < 0.001) which is self-explanatory for statistically significance. One should not use abbreviations such as ‘NS’ or ‘Sig’ for describing (non-) significance. Abbreviations should be described for all presented tables. A typical example of a table can be seen in Figure 4 .

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Example of presenting a table

Graphical images

Similar to tables, the graphs and diagrams give a bird's-eye view of the entire data and therefore may easily be understood. bar diagrams (simple, multiple or component), pie charts, line diagrams, pictograms and spot maps suit qualitative data more whereas the histograms, frequency polygons, cumulative frequency, polygon scatter diagram, box and whisker plots and correlation diagrams are used to depict quantitative data. Too much presentation of graphs and images, selection of inappropriate or interchanging of graphs, unnecessary representation of three-dimensional graph for one-dimensional graphs, disproportionate sizes of length and width and incorrect scale and labelling of an axis should be avoided. All graphs should contain legends, abbreviation descriptions and a footnote. Appropriate labelling of the x - and the y -axis is also essential. Priori decided scale for axis data should be considered. The ‘error bar’ represents SDs or IQRs in the graphs and should be used irrespective of whether they are bar charts or line graphs. Not showing error bars in a graphical image is a gross mistake. An error bar can be shown on only one side of the line graph to keep it simple. A typical example of a graphical image can be seen in Figure 5 . The number of subjects (sample) is to be mentioned for each time point on the x -axis. An asterisk (*) needs to be put for data comparisons having statistically significant P value in the graph itself and they are self-explanatory with a ‘stand-alone’ graph.

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Example of an incorrect (a) and correct (b) image

Once the results have been adequately analysed and described, the next step is to draw conclusions from the data and study. The main goal is to defend the work by staging a constructive debate with the literature.[ 16 ] Generally, the length of the ‘ Discussion ’ section should not exceed the sum of other sections (introduction, material and methods, and results).[ 17 ] Here the interpretation, importance/implications, relevance, limitations of the results are elaborated and should end in recommendations.

It is advisable to start by mentioning the RQ precisely, summarising the main findings without repeating the entire data or results again. The emphasis should be on how the results correlate with the RQ and the implications of these results, with the relevant review of literature (ROL). Do the results coincide with and add anything to the prevalent knowledge? If not, why not? It should justify the differences with plausible explanation. Ultimately it should be made clear, if the study has been successful in making some contribution to the existing evidence. The new results should not be introduced and any exaggerated deductions which cannot be corroborated by the outcomes should not be made.

The discussion should terminate with limitations of the study,[ 17 ] mentioned magnanimously. Indicating limitations of the study reflects objectivity of the authors. It should not enlist any errors, but should acknowledge the constraints and choices in designing, planning methodology or unanticipated challenges that may have cropped up during the actual conduct of the study. However, after listing the limitations, the validity of results pertaining to the RQ may be emphasised again.

This section should convey the precise and concise message as the take home message. The work carried out should be summarised and the answer found to the RQ should be succinctly highlighted. One should not start dwelling on the specific results but mention the overall gain or insights from the observations, especially, whether it fills the gap in the existing knowledge if any. The impact, it may have on the existing knowledge and practices needs to be reiterated.

What to do when we get a negative result?

Sometimes, despite the best research framework, the results obtained are inconclusive or may even challenge a few accepted assumptions.[ 18 ] These are frequently, but inappropriately, termed as negative results and the data as negative data. Students must believe that if the study design is robust and valid, if the confounders have been carefully neutralised and the outcome parameters measure what they are intended to, then no result is a negative result. In fact, such results force us to critically re-evaluate our current understanding of concepts and knowledge thereby helping in better decision making. Studies showing lack of prolongation of the apnoea desaturation safety periods at lower oxygen flows strengthened belief in the difficult airway guidelines which recommend nasal insufflations with at least 15 L/min oxygen.[ 19 , 20 , 21 ]

Publishing the dissertation work

There are many reporting guidelines based upon the design of research. These are a checklist, flow diagram, or structured text to guide authors in reporting a specific type of research, developed using explicit methodology. The CONSORT[ 22 ] and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiatives,[ 23 ] both included in the Enhancing the Quality and Transparency of Health Research (EQUATOR) international network, have elaborated appropriate suggestions to improve the transparency, clarity and completeness of scientific literature [ Figure 6 ].

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Equator publishing tree

All authors are advised to follow the CONSORT/STROBE checklist attached as Supplementary file 4 , when writing and reporting their dissertation.

For most dissertations in Anaesthesiology, the CONSORT, STROBE, Standards for Reporting Diagnostic accuracy studies (STARD) or REporting recommendations for tumour MARKer prognostic studies (REMARK) guidelines would suffice.

Abstract and Summary

These two are the essential sections of a dissertation.

It should be at the beginning of the manuscript, after the title page and acknowledgments, but before the table of contents. The preparation varies as per the University guidelines, but generally ranges between 150 to 300 words. Although it comes at the very beginning of the thesis, it is the last part one writes. It must not be a ‘copy-paste job’ from the main manuscript, but well thought out miniaturisation, giving the overview of the entire text. As a rule, there should be no citation of references here.

Logically, it would have four components starting with aims, methods, results, and conclusion. One should begin the abstract with the research question/objectives precisely, avoiding excessive background information. Adjectives like, evaluate, investigate, test, compare raise the curiosity quotient of the reader. This is followed by a brief methodology highlighting only the core steps used. There is no need of mentioning the challenges, corrections, or modifications, if any. Finally, important results, which may be restricted to fulfilment (or not), of the primary objective should be mentioned. Abstracts end with the main conclusion stating whether a specific answer to the RQ was found/not found. Then recommendations as a policy statement or utility may be made taking care that it is implementable.

Keywords may be included in the abstract, as per the recommendations of the concerned university. The keywords are primarily useful as markers for future searches. Lastly, the random reader using any search engine may use these, and the identifiability is increased.

The summary most often, is either the last part of the Discussion or commonly, associated with the conclusions (Summary and Conclusions). Repetition of introduction, whole methodology, and all the results should be avoided. Summary, if individually written, should not be more than 150 to 300 words. It highlights the research question, methods used to investigate it, the outcomes/fallouts of these, and then the conclusion part may start.

References/bibliography

Writing References serves mainly two purposes. It is the tacit acknowledgement of the fact that someone else's written words or their ideas or their intellectual property (IP) are used, in part or in toto , to avoid any blame of plagiarism. It is to emphasise the circumspective and thorough literature search that has been carried out in preparation of the work.

Vancouver style for referencing is commonly used in biomedical dissertation writing. A reference list contains details of the works cited in the text of the document. (e.g. book, journal article, pamphlet, government reports, conference material, internet site). These details must include sufficient details so that others may locate and access those references.[ 24 ]

How much older the references can be cited, depends upon the university protocol. Conventionally accepted rule is anywhere between 5-10 years. About 85% of references should be dispersed in this time range. Remaining 15%, which may include older ones if they deal with theories, historical aspects, and any other factual content. Rather than citing an entire book, it is prudent to concentrate on the chapter or subsection of the text. There are subjective variations between universities on this matter. But, by and large, these are quoted as and when deemed necessary and with correct citation.

Bibliography is a separate list from the reference list and should be arranged alphabetically by writing name of the ‘author or title’ (where no author name is given) in the Vancouver style.

There are different aspects of writing the references.[ 24 ]

Citing the reference in the form of a number in the text. The work of other authors referred in the manuscript should be given a unique number and quoted. This is done in the order of their appearance in the text in chronological order by using Arabic numerals. The multiple publications of same author shall be written individually. If a reference article has more than six authors, all six names should be written, followed by “ et al .” to be used in lieu of other author names. It is desirable to write the names of the journals in abbreviations as per the NLM catalogue. Examples of writing references from the various sources may be found in the Supplementary file 5 .

Both the guide and the student have to work closely while searching the topic initially and also while finalising the submission of the dissertation. But the role of the guide in perusing the document in detail, and guiding the candidate through the required corrections by periodic updates and discussions cannot be over-emphasised.

Assessment of dissertations

Rarely, examiners might reject a dissertation for failure to choose a contemporary topic, a poor review of literature, defective methodology, biased analysis or incorrect conclusions. If these cannot be corrected satisfactorily, it will then be back to the drawing board for the researchers, who would have to start from scratch to redesign the study, keeping the deficiencies in mind this time.

Before submission, dissertation has to be run through “plagiarism detector” software, such as Turnitin or Grammarly to ensure that plagiarism does not happen even unwittingly. Informal guidelines state that the percentage plagiarism picked up by these tools should be <10%.

No work of art is devoid of mistakes/errors. Logically, a dissertation, being no exception, may also have errors. Our aim, is to minimise them.

The dissertation is an integral part in the professional journey of any medical post-graduate student. It is also an important responsibility for a guide to educate his protégé, the basics of research methodology through the process. Searching for a gap in literature and identification of a pertinent research question is the initial step. Careful planning of the study design is a vitally important aspect. After the conduct of study, writing the dissertation is an art for which the student often needs guidance. A good dissertation is a good description of a meticulously conducted study under the different headings described, utilising the various reporting guidelines. By avoiding some common errors as discussed in this manuscript, a good dissertation can result in a very fruitful addition to medical literature.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

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