med dissertation

• Office of the Deputy Dean
• MD Admissions Committee
• Progress Committee
• EPCC Committee Minutes
• Thesis Chair Committee
• Curriculum Mapping Documents
• PreClerkship Policies
• Clerkship & ATP Policies
• University Policy Links
• Self-Study Task Force
• You said . . . We did . . .
• Faculty Training
• Renovation & Expansion of Student Space
• Faculty Mentor Responsibilities and Resources
• Departmental Thesis Chairs
• First-Year Summer Research
• Short-term Research
• One-year Fellowships
• Travel Info & Reimbursement
• Research Didactics
• START Summer Program
• Master of Health Science
• Student Research Day
• Forms, Deadlines & Funding
• Student Research Team
• Research Tradition
• The Yale System
• How to Apply
• Dates and Deadlines
• Fee Waivers
• Pre-medical Requirements
• Admissions Team
• Electives & Subinternships
• Staying for a Fifth Year
• Academic Advisors
• Performance Improvement
• Residency Applications
• Meet our Staff & Make an Appointment
• Wellness Programming: Upcoming Events
• Peer Advocate Program
• Day in the life of Med student
• Hear our Experiences
• Student Affairs Team
• Application Process
• International Students
• 2024-2025 Budget
• 2023-2024 Budget
• 2022-2023 Budget
• 2021-2022 Budget
• 2020-2021 Budget
• 2019-2020 Budget
• 2018-2019 Budget
• 2017-2018 Budget
• 2016-2017 Budget
• 2015-2016 Budget
• 2014-2015 Budget
• Research Funding, Extended Study and Financial Aid
• Frequently Asked Questions
• PA Online Student Budget
• FAFSA Application
• CSS Profile Application
• How to Avoid Common Errors
• Student Billing Information
• Financial Literacy Information
• External Scholarships
• Financial Aid Team
• Certificate in Global Medicine
• Topics in Global Medicine and Health
• Global Health Seminar
• Summer Research Abroad
• Electives at Other Yale Graduate Schools
• About the Course
• South Africa
• Connecticut
• Dominican Republic
• Lectures, Series, & Conferences
• Community & Advocacy Opportunities
• Faculty Advisors & Mentors
• Global Health Team
• Services & Facilities
• Program & Faculty Development
• Education & Research
• Simulated Participants
• Simulation Academy at Yale – Youth Entering Science (SAY-YES!)
• Faculty & Staff
• Advisory Board
• HAVEN Free Clinic
• Neighborhood Health Project
• Humanities in Medicine
• Biomedical Ethics
• Yale Journal of Biology & Medicine
• University Engagement Opportunities
• Community Engagement Opportunities
• Competencies
• Guiding Principles
• Graduation Requirements
• Year 1 Curriculum
• Year 2 Curriculum
• Introduction to the Profession (iPro)
• Scientific Foundations
• Genes and Development
• Attacks and Defenses
• Homeostasis
• Energy and Metabolism
• Connection to the World
• Across the Lifespan
• Professional Responsibility
• Scientific Inquiry
• Populations & Methods
• Biochemistry
• Cell Biology
• Diagnostic Methods
• Health Equity
• Pharmacology
• Communications Skills
• Clinical Reasoning
• Palliative Care
• Physical Examination
• Point of Care Ultrasound
• Early Clinical Experiences
• Emergency Medicine
• Primary Care
• Internal Medicine
• Recommended Readings
• Online Learning
• Interprofessional Educational
• Anesthesiology
• Child Study Center
• Clinical Longitudinal Elective
• Definitions
• Dermatology
• Diagnostic Imaging
• Family Medicine
• Interventional Radiology
• Laboratory Medicine
• Neurosurgery
• Obstetrics, Gynecology & Reproductive Sciences
• Ophthalmology and Visual Science
• Orthopaedics and Rehabilitation
• Therapeutic Radiology
• Elective Dates
• WEC Faculty
• Non-Clinical Electives
• Coaching Program
• Patient-Centered Language
• Race & Ethnicity
• Sex & Gender
• Full Glossary of Terms
• About The Inclusive Language Initiative
• Glossary Bibliography
• Curriculum Team
• Faculty Attestation
• Visiting Student Scholarship Program
• International Student FAQs

INFORMATION FOR

• Residents & Fellows
• Researchers

Formal MD Thesis Requirement

All students at Yale School of Medicine engage in research and are required to write an MD thesis during medical school. The only exceptions are students who have earned a PhD degree in the health sciences before matriculation and students enrolled in Yale’s MD/PhD program. The YSM MD Thesis is under the governance of the EPCC, which meets regularly to recommend rules, regulations, and deadlines.

Deadlines/Important Dates

Thesis approval process, thesis awards, 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, student evaluation of thesis advisor.

• Yale School of Medicine Digital Thesis Depositor’s Declaration Form
• Thesis Deadline Extension Request Form

Thesis Deadlines for the 2023-2024 Academic Year

Md students:.

The Office of Student Research, in conjunction with the Dean’s Office, has established the following deadlines for theses submitted in partial fulfillment of the requirements for graduation in May 2024. The deadlines ensure that (1) students have sufficient time to complete their theses; (2) that there is sufficient time for rigorous departmental review and subsequent revision by students before final approval. These deadlines are strictly followed. Students are strongly encouraged to submit their theses well before the Class of 2024 Thesis Deadlines provided below. This timeliness will provide students, advisors, and sponsoring departments sufficient time for useful review and revision. It should be recognized by all concerned that the integrity of the thesis requirement and effective, rigorous review requires adherence to these deadlines. OSR will hold periodic “Thesis Check-in Sessions” via zoom for the Class of 2024 and will send periodic reminder emails with more detailed instructions as these deadlines approach.

*Students missing the August 4th, January 19th, and/or March 29th deadlines will be referred to the Progress Committee to ensure they receive adequate support to make progress towards this graduation requirement. Students missing the January 19th and/or March 29th deadlines will be ineligible for thesis prizes at graduation.

Extensions beyond the above thesis deadlines will be granted only for special circumstances and must have the approval of the student’s thesis mentor/advisor, academic advisor, and the Departmental Thesis Chairperson . Students seeking an extension for the January 19, 2024, deadline must submit a Thesis Deadline Extension Request Form to their Academic Advisor, and the Departmental Thesis Chair, for approval. Students missing the August 4th, January 19th, and/or March 29th deadlines will be referred to the Progress Committee to ensure they receive adequate support to make progress towards this graduation requirement. In the event of an extension, if granted, the following ABSOLUTE Class of 2024 Thesis Extension Deadlines will apply:

*All late theses require an extension. The student must submit the Thesis Deadline Extension Request Form before January 19, 2024.

MD/MHS Students:

Consistent with degree requirements, MD/MHS students must present their thesis to their three-person committee prior to the January 19th deadline. Students are encouraged to start arranging the date of this committee meeting in the fall to avoid unanticipated delays.

MD/PhD Students:

A different process applies to students in the MD/PhD program. For students enrolled in the combined MD/PhD Program, the dissertation submitted to and approved by the Graduate School will satisfy the MD thesis requirement. Therefore, MD/PhD students who have already defended their dissertation and received their PhD should provide this information to OSR via email as soon as possible.

To ensure compliance with YSM graduation deadlines, MD/PhD students in the class of 2024 who have not defended and submitted their dissertation to the Graduate School by the October 1, 2023, deadline will need to submit a copy of their dissertation directly to OSR via the MD/PhD Box Upload Link by March 15, 2024. OSR will convene a committee to review the dissertation, obtain feedback, and provide approval for graduation. Please note that MD/PhD students must also defend and submit their dissertation to the Graduate School no later than March 15, 2024, to meet the Graduate School spring degree deadline for conferral of the PhD degree. MD/PhD students who have not yet defended their dissertation should provide this information to OSR. If there are any questions about the process, please contact the MD/PhD Office.

Financial support is not provided for writing the thesis.

Thesis Preparation and Approval

Preparation for thesis submission begins in the summer of the fourth year with the OSR leadership. At this time, timeline and practices are distributed via email and reviewed with students in class meetings. Because thesis approval is a lengthy process involving three levels of review, students are encouraged to manage their time well and start writing their first draft early in the fall semester of their final year of medical school. A suggested timeline is provided below.

July : Thesis deadlines are distributed via email to all students in the graduating class and an informational session is held. Students should be on track to complete their thesis research by mid-fall. Any student anticipating a challenge in this regard should contact the OSR as soon as possible. All students expecting to graduate in May of a given year must, provide the OSR with information regarding their thesis title and mentor/advisor. Students will receive an email from the OSR containing a Medtrics link requesting this information. The OSR will contact all thesis mentors/advisors to confirm this role and to provide information and expectations regarding the thesis process.

August – December : Students should be finalizing research and writing their thesis draft. As the semester progresses, activities should shift from the data generation/analysis to the writing of the actual thesis. Students should do their best to complete the first draft of the thesis by mid-late December. Because students are also involved in the residency application and interview process, they are discouraged from starting new projects at this time.

December – January : This period is devoted to reviewing and editing of thesis draft that is ultimately approved by their thesis mentor/advisor and submitted by the student to the Thesis Chair of their sponsoring department. The YSM thesis mentor/advisor will be asked to complete a thesis assessment that evaluates the student’s mastery of YSM’s research-related educational objectives and provides formative summative feedback to the student.

January – March : The Departmental Thesis Chair coordinates thesis review by external reviewers. An “external reviewer” is defined as an individual who is not directly involved in the project. This individual may be a Yale faculty member internal or external to YSM or may hold a faculty appointment at an outside institution. This reviewer is required to complete a thesis assessment and provide formative summative feedback, as well as recommendations for any required changes, to the thesis. Departmental Thesis Chairs review assessments, notify students of departmental approval, and transmit these approvals to the OSR.

March : Theses and their associated assessments undergo school-level review by the OSR. Students receive YSM approval of their thesis along with summative feedback obtained during the review process. Students incorporate any required changes into their thesis and upload to the Yale Medicine Digital Thesis Library/Eli Scholar via the ProQuest platform (see below).

April : The OSR confirms that theses have been deposited into the Yale Medicine Digital Thesis Library and the registrar receives the names of students who have completed the thesis requirement.

The central role of the medical student thesis is to assess student’s performance on the YSM’s research-related educational objectives. As such, all students are expected to produce an excellent piece of scholarly work. In recognition of these achievements, the OSR has worked to develop an award process that celebrates the wonderful research being done by our students without creating a competitive atmosphere surrounding the thesis. Hence, thesis awards are based on competency-based assessments submitted by thesis mentors/advisors and reviewers during the approval process, and internal review of the final thesis that was deposited into the Yale Medicine Digital Thesis Library. Consistent with all other graduation prizes, YSM MD Thesis Awards will remain confidential until they are announced in the YSM Commencement Program on May 20, 2024. While some departments may elect to confer thesis “honors” based upon their own internal review, this recognition is distinct from YSM graduation prizes and is not under OSR’s purview.

Read about the required formatting and components for the thesis .

See helpful examples for reference section formatting.

Read about avoiding the risk of copyright violation and liability when submitting your MD Thesis.

Learn more about submitting a thesis to the Yale Medicine Thesis Digital Library .

Learn more about the Thesis Depositors Declaration Form.

Learn more about evaluating your experience with your thesis advisor .

Apply for a Thesis Extension

Read about the required formatting and components for the thesis.

Yale Journal of Biology and Medicine

Learn more about the journal or submit a manuscript.

• Research article
• Open access
• Published: 10 December 2020

Qualitative research methods in medical dissertations: an observational methodological study on prevalence and reporting quality of dissertation abstracts in a German university

• Charlotte Ullrich   ORCID: orcid.org/0000-0002-9757-913X 1 ,
• Anna Stürmlinger 1 ,
• Michel Wensing 1 &
• Katja Krug 1  

BMC Medical Research Methodology volume  20 , Article number:  301 ( 2020 ) Cite this article

4957 Accesses

5 Citations

1 Altmetric

Metrics details

Qualitative methods offer a unique contribution to health research. Academic dissertations in the medical field provide an opportunity to explore research practice. Our aim was to assess the use of qualitative methods in dissertations in the medical field.

By means of a methodological observational study, an analysis of all academic medical dissertations’ abstracts between 1998 and 2018 in a repository databank of a large medical university faculty in Germany was performed. This included MD dissertations (Dr. med. (dent.)) and medical science dissertations (Dr. sc. hum.). All abstracts including “qualitativ*” were screened for studies using qualitative research methods. Data were extracted from abstracts using a category grid considering a) general characteristics (year, language, degree type), b) discipline, c) study design (mixed methods/qualitative only, data conduction, data analysis), d) sample (size and participants) and e) technologies used (data analysis software and recording technology). Thereby reporting quality was assessed.

In total, 103 abstracts of medical dissertations between 1998 and 2018 (1.4% of N  = 7619) were included, 60 of MD dissertations and 43 of medical sciences dissertations. Half of the abstracts ( n  = 51) referred to dissertations submitted since 2014. Most abstracts related to public health/hygiene ( n  = 27) and general practice ( n  = 26), followed by medical psychology ( n  = 19). About half of the studies ( n  = 47) used qualitative research methods exclusively, the other half ( n  = 56) used mixed methods. For data collection, primarily individual interviews were used ( n  = 80), followed by group interviews ( n  = 33) and direct observation ( n  = 11). Patients ( n  = 36), physicians ( n  = 36) and healthcare professionals ( n  = 17) were the most frequent research participants. Incomplete reporting of participants and data analysis was common ( n  = 67). Nearly half of the abstracts ( n  = 46) lacked information on how data was analysed, most of the remaining ( n  = 43) used some form of content analysis. In summary, 36 abstracts provided all crucial data (participants, sample size,; data collection and analysis method).

A small number of academic dissertations used qualitative research methods. About a third of these reported all key aspects of the methods used in the abstracts. Further research on the quality of choice and reporting of methods for qualitative research in dissertations is recommended.

Peer Review reports

Qualitative research methods offer a unique contribution to health research, particular for exploration of the experiences of patients, healthcare professionals and others [ 1 , 2 , 3 , 4 , 5 ]. While (general) epidemiology primarily addresses health and healthcare in populations and clinical research concentrates on medical interventions and health prognosis, qualitative research methods focus on different actors’ perspectives, experiences and behaviours in health-related contexts. Qualitative research entails a broad spectrum of methods of data conduction and data analysis: individual interviews illuminate individual perceptions [ 6 ], group interviews deliver insights into shared norms and opinions [ 7 ], direct observations facilitate understandings of behaviours in healthcare practice [ 8 , 9 , 10 ] and documents can offer insights into discourses and self-representations [ 11 ]. For data analysis, methods combining inductive and deductive steps are most suitable for exploratory research questions utilizing existing results, theories and concepts [ 12 ]. Given these prospects, little is known on the practice of applying qualitative research methods, especially concerning medicine.

In dissertations, a foundation for future scientific work is laid; therefore, guidance and rigour are of special importance [ 13 ]. Dissertations in medical departments provide a good opportunity to explore research practices of students and young academics. In Germany, about 60% of all graduating medical students complete an academic dissertation [ 14 ], which they usually finish parallel to medical school within a full-time equivalent of about a year [ 15 , 16 , 17 , 18 ]. As a by-product, medical doctoral students are increasingly among the authors of published research, holding first-authorship in about 25% [ 18 , 19 , 20 ].

In Germany, basic scientific training is a required part of the medical curriculum and recent policies put even more emphasis on the development of scientific competencies [ 15 , 21 , 22 ]. National regulations specify scientific competencies giving explicit recommendations for quantitative methods. Medical students have rarely received training in qualitative methods. However, health care professions and qualitative methods share a perspective directed to practice and interactions. Interviews and observations are already commonly used as clinical and diagnostic tools.

In addition to the doctoral degrees for medical and dental graduates (Doctor medicinae (dentariae), Dr. med. (dent.)), students with other disciplinary backgrounds (e.g. natural scientists, psychologists and social scientists) complete dissertations at medical faculties in Germany (often labelled Doctor scientiarum humanarum, Dr. sc. hum. or Doctor rerum medicarum, Dr. rer. medic.). Although regulations differ slightly, the degrees are usually situated within and regulated by the same institutional culture and context (e.g. faculty, department, supervision and aspired publications).

The aim of this study was to understand the current practice of applying qualitative research methods helping identify gaps in reporting and need for guidance. By means of a methodological study – a subtype of observational studies that evaluates the design, analysis of reporting of other research-related reports [ 23 ] – we investigated volume and variety of the use of qualitative research methods in dissertations at a German medical faculty. Hereby we wanted to inform methodological advances to health research and outline implications for medical education in scientific competencies training.

Search strategy

Dissertations in the medical field were retrospectively assessed: In a document analysis, all dissertation abstracts at one medical faculty were reviewed. This faculty was chosen as it is one of the oldest and largest medical faculties in Germany, with a strong research tradition and a high dissertation rate among graduating students. All abstracts from 01/01/1998 to 31/12/2018, which were publicly available in the repository databank of the university, were reviewed. This included MD dissertations (Dr. med. (dent.)) and medical science dissertations (Dr. sc. hum.) written in German or English. All types of studies using qualitative research methods, all types of human participants, all types of interventions and all types of measures were eligible. We focused on abstracts, because full text dissertations are not publicly available and are helpful to get an overview of a number of method-related issues. Although serving as a proxy, abstracts should provide a sufficient summary of the dissertation, including crucial information on study design, independently from the full text. In the databank, relevant documents had to be labelled a) “abstract of a medical dissertation” (referring to both degree types). To further identify dissertations using qualitative methods b) the search term “qualitativ*” was used as an inclusion criterium.

Selection and data extraction

All identified abstracts were pre-screened independently by two researchers (AS, LS) and then reviewed by the main research team (KK, AS, CU) excluding abstracts using “qualitativ*” only in respect to non-methods-related issues (e.g. quality of life). Data on a) general characteristics (year, language, degree type), b) discipline, c) study design (mixed methods/qualitative only, data conduction, data analysis), d) sample (size and participants) and e) technologies used (data analysis software and recording technology) (see App. 2) was then extracted independently by two team members (AS, LS) and crossed-checked (KK, CU). Data extraction was initially guided by two widely used reporting guidelines for qualitative health research articles [ 24 , 25 ] and adapted to reflect the abstract format: Abstracts provided comparable information on the set-up of study design and sample. Reporting of results was not assessed due to heterogeneity and briefness. Data extraction forms were piloted and adjusted to inductive findings. Disagreements were discussed, assessed and solved by consensus by the main research team (KK, AS, CU). Extracted data were analysed and reported as absolute and relative frequencies. As all abstracts were available, no further data was obtained from authors.

Search results

Out of a total of 7619 dissertation abstracts, 296 dissertations were initially identified. Of these, 173 abstracts were excluded from the study as “qualitativ*” in these abstracts did not refer to the research method. Additionally, 20 abstracts (12 medicine, 8 medical science) were not further included in the analysis due to an ambiguous and inconclusive use of the label “qualitative methods” and/or restricted comparability with the otherwise pre-dominant interview-based study designs: a) a qualitative research design was stated, but no further information on the approach was given ( n  = 7), b) no explicit distinction was made between qualitative research design and a clinical diagnostic approach ( n  = 4), c) the qualitative approach comprised of additional free text answers in written questionnaires only ( n  = 6), and d) only document analysis or observation was used ( n  = 3). In total, 103 abstracts (1.4% of 7619) were included in the analysis.

Low but increasing use

Since 1998, the number of dissertations applying qualitative methods has continually increased while the total number of dissertations remained stable (between n  = 314 in 2006 and n  = 410 in 1999 and 2008, M (1998–2018) = 362.8, SD = 26.1) (Fig.  1 ). Before 2005 there was yearly not more than one dissertation that used qualitative methods. Since then, the number has steadily raised to more than 10 dissertations per year, equivalent to an increase from 0.28% in 1998 to 3.42% in 2018 of all listed dissertation abstracts per year.

Number of all dissertations and dissertations using qualitative methods per year between 1998 and 2018

General characteristics

Abstracts nearly equally referred to dissertations leading to an MD degree (Dr. med. n  = 57, Dr. med. Dent. n  = 3) and medical science degree (Dr. sc. hum. n  = 43), respectively. The included dissertation abstracts were based in 12 different sub-specialties , most in general practice ( n  = 26), in public health and hygiene ( n  = 27) and medical psychology ( n  = 19); the Dr. med. (dent.) abstracts having a higher share in general practice ( n  = 21) and the Dr. sc. hum. abstracts in public health/hygiene ( n  = 16) (s. Table  1 ).

Most abstracts followed at least roughly the common structure of background, methods, results and conclusion. The length of the abstracts varied between less than one and more than three pages, with most abstracts being one to two pages long; 77 abstracts were written in German and 26 in English.

Study design

About half of the studies used qualitative research methods exclusively ( n  = 47; 60% of Dr. med. (dent.) abstracts, 26% of Dr. sc. hum. abstracts), the other half mixed methods ( n  = 56; 40% of Dr. med. (dent.) abstracts, 74% of Dr. sc. hum. abstracts; Table 1 ). Individual interviews were the most common form of data collection ( n  = 80), followed by group interviews ( n  = 33) and observation ( n  = 11). In total, 23 abstracts indicated the use of a combination of different qualitative methods of data conduction, all of these included individual interviews. For documentation/recording, when reported ( n  = 37), audio recording was used in most cases ( n  = 3).

Little difference regarding method of data conduction were found between pure qualitative and mixed-methods designs. Mixed methods studies rather included physicians ( n  = 21) and used predominantly general content analysis ( n  = 14), when reported; whereas qualitative studies rather included patients ( n  = 28) and used predominantly both content analysis ( n  = 14) and content analysis following Mayring ( n  = 12). Overall incomplete reporting was more common in mixed-method studies ( n  = 41) than qualitative studies ( n  = 26, 55.3%) (see App. 2).

Sample size varied widely: Overall, 67 abstracts provided a sample size. Of those, a median number of 29 people (min-max: 2–136) participated in individual and group interviews. Only in Dr. sc. hum. dissertations using mixed methods, lower median sample sizes were reported for the qualitative part (Md = 22, min-max: 6–110; n  = 17) compared to dissertations using qualitative methods only (medical science ( n  = 7): Md = 31, min-max: 16–50; MD ( n  = 29): Md = 29, min-max: 7–136) and Dr. med. (dent.) dissertations with mixed methods (Md = 30, min-max: 2–62; n  = 14). In individual interviews, when sample size was reported ( n  = 55, 69% of 80), it distributed roughly equally in the ranges of 1–10, 11–20, 21–30, 31–50 and above 50 (Md = 25; min-max: 2–110). For the 33 dissertations using group interviews, the number of groups is given in 20 abstracts, the number of participants in 15 abstracts. Between 1 and 24 group interviews were conducted with a median total of 24 participants (min-max: 2–65) (see Table 1 ).

Patients ( n  = 36) and physicians ( n  = 36) were the overall most frequent research participants , followed by other health care professionals ( n  = 17), students ( n  = 11) and relatives of patients ( n  = 7). Other participants ( n  = 16) included: representatives of self-help organizations and other experts, educators such as teachers and policy makers. In 33% ( n  = 31) of the abstracts, more than one participant group was included, 6.8% ( n  = 7) did not specify research participants. While MD dissertations predominantly included physicians ( n  = 27) and patients ( n  = 19), Dr. sc. hum. dissertations included mostly patients ( n  = 17) and other participants ( n  = 10).

Data analysis

For data analysis, if reported ( n  = 57), content analyses were the most common used method ( n  = 42), including the highly deductive approach formulated by Mayring [ 26 ] ( n  = 16), mostly used in MD dissertations ( n  = 14). Among other reported methods ( n  = 15), grounded theory ( n  = 5) was the most common approach; rarely mentioned methods include framework analysis and non-specific analysis combining inductive and deductive approaches. Forty-six abstracts did not provide information on the analysis method used (38.3% of MD abstracts, 53% of medical science abstracts). If reported ( n  = 24), ATLAS.ti ( n  = 14), MAXQDA ( n  = 3) and NVivo ( n  = 3) were mentioned most frequently as qualitative data analysis programs.

In summary, 36 abstracts provided all crucial data (participants: sample size, characteristics, i.e. healthcare professional/patient; data collection and analysis method). Thus, 58% ( n  = 35) of MD dissertation abstracts and 74% ( n  = 32) of Dr. sc. hum. dissertation abstracts had at least one missing information.

The results show a low but increasing use of qualitative research methods in medical dissertations. Abstracts nearly equally referred to dissertations leading to an MD degree and medical science doctorate respectively; half of which were submitted since 2011. Qualitative methods were used in several departments, most frequently in those for general practice, public health and medical psychology mirroring an already known affinity between the objective of certain medical disciplines and perspective qualitative methods [ 27 , 28 ].

About half of the studies used qualitative research methods exclusively, the other half mixed methods: While some differences were found, due to short format and sparse information within the abstract a strict differentiation between qualitative approaches alone and combined quantitative and qualitative designs was not made. Little difference according to degree type was observed. This points to a strong shared dissertation culture, that balances and conceals differences in academic training between medical students and graduates from other, quite diverse, disciplines (e.g. from humanities, natural and social sciences) pursuing a doctorate at a medical faculty.

Limited variety in methods used

The results show a strong preference for certain methods in data conduction, research participants and data analysis: Individual and group interviews were predominant as well as content analysis, especially Mayring’s deductive approach. All in all, a limited use of the broad spectrum of qualitative research methods can be observed. Interviews are important to gain insights on actors’ perspective [ 6 ]; however, they have limited information value when it comes to actual processes and practice of health care. To investigates those, additional direct observation would be suitable [ 8 , 9 ]. In group interviews shared norms and opions can be observed, they are not suitable to capture individual perspectices. Group interviews go along with higher time and efforts regarding scheduling, interview guidance and data analysis [ 7 ]. Within the dissertations, documents are rarely used as data within the dissertations, but could be useful readily available documents.

Included research participants were mostly patients and physicians. This might be due to the research questions posed or the availability of participants. However, to reflect the complexity of health care a higher diversity of research questions, expanding participants (e.g. other health care professionals and caregivers) and based on a thorough knowledge of available methods, including qualitative approaches, might be needed.

As for methods of analysis, the results show a predominant use of a form of content analysis, with a strong affinity to quantitative analysis often limited to description forgoing in-depth analysis. As qualitative methods belong to the interpretative paradigm, most qualitative methodologies emphasize inductive analyses (e.g. Grounded Theory) and/or a combination of induction and deduction [ 12 , 29 ]. By using primarily descriptive content analysis the full potential of qualitative research and depth of the data to gain new a insights are thus neglected. Since knowledge about and application of qualitative methods are not part of the medical curriculum, doctoral students lack training in using qualitative methods and grasping the possibilities these methods convey for in-depth original knowledge.

Incomplete reporting

One fundamental principle of good research practice is accurate reporting. For empirical research, reporting on research design and methods is crucial to ensure comparability and reflect reach of research results. Within medicine and other health sciences, while debated [ 30 ], reporting guidelines are increasingly used to guarantee a basic standard. While qualitative research designs differ from clinical and quantitative designs regarding theoretical and methodological background, study aims and research process, rigorous reporting is a shared standard: this includes reporting on data conduction, sampling, participants and data analysis (e.g. COREQ [ 24 ]).

In our study, incomplete reporting regarding research design and methods was common. Especially, information on methods of data analysis was missing in about half of the abstracts reflecting the limited awareness of the plethora of qualitative analysis methods. Additionally, a third of the abstracts did not provide information on sample size. Although the importance of a “sufficient” sample size is controversially discussed, identifying the sources and putting their contributions into perspective is a paramount characteristic of qualitative research [ 31 , 32 , 33 ]. All in all, incomplete reporting was common ( n  = 67). Additionally, out of 123 initially identified abstracts, 20 had to be excluded from the analysis as comparability was not given mainly due to the inconclusive use of the term qualitative methods.

Several issues should be considered when interpreting the findings from this study. As a case study at one large faculty, which has a strong research orientation, the generalizability of the findings is uncertain. It seems unlikely that the quality of reporting is better in other medical faculties in Germany, but the prevalence of using qualitative methods might be higher. Character and role of the abstracts might not be as apparent as in journal papers, as they serve as a summary of the dissertation and are listed within the online repository databank only. The relation of reporting quality of those abstracts and the full text dissertation or even publication is unknown. Presentation of results was not assessed as information in abstracts were brief and heterogenous. Additionally, insights are limited by the structure of the repository databank itself, i.e. sub-disciplines are combined that sometimes cover distinct research fields or did evolve as separate specialties. All in all, however, the results mirror the critique on the lack of scientific training in medical education [ 17 , 22 , 34 , 35 ] and the want of sufficient reporting in medicine and health science, irrespective of study design [ 36 ].

While recent policies put a strong emphasis on strengthening scientific competences in medical education in Germany [ 15 , 21 , 22 ], especially MD dissertations are only in some degree comparable to dissertation thesis of other disciplines and medical dissertations internationally: In Germany, about 60% of all graduating medical students complete an academic dissertation [ 14 ], which they usually finish parallel to medical school within a full-time equivalent of about a year [ 15 , 16 , 17 , 18 ]. Graduate programs that exclusively dedicate 1 year for pursuing a dissertation are still discussed as innovative [ 35 ]. Additionally, the expertise of supervisors was not assessed. In a recent opinion paper, Malterud et al. [ 37 ] called for supervisors and dissertation committees holding corresponding methodological skills and experience as well as an academic consensus regarding scientific rigour to ensure high quality theses using qualitative methods. Missing standards in supervision and reporting might have led to the observed results in our study.

Qualitative research methods offer a unique scientific benefit to health care, including medicine. Our results show that within dissertation research, the number of dissertations applying qualitative methods has continually increased mirroring an overall trend in health research. To improve reach and results, a broader spectrum of qualitative methods should be considered when selecting research designs, including e.g. (direct) observation, document and analysis strategies, that combine inductive and deductive approaches. Same holds true for including a more diverse body of research participants. More broadly, reporting and academic practice should be improved.

Reporting guidelines can not only help to improve the quality of reporting but also be used as a tool to supervising graduate students steps commonly associated with qualitative research methods. So far, however, reporting guidelines mainly target full and/or published papers. Still, some reporting guidelines for abstracts are already available [ 38 , 39 , 40 , 41 ], that could be adapted for dissertation research in health science.

In academic practice, skilled supervision alongside transparent and method-appropriate criteria are the precondition for confident and courageous dissertation research that increases understanding and challenges existing knowledge of health care research. Educational programs strengthening research and reporting skills – within and beyond qualitative methods – should be implemented into medical education more profoundly, at the latest in doctoral training.

Availability of data and materials

The data of the repository databank is semi-public and can be accessed from the corresponding author upon reasonable request. A data extraction table is available in App. 2.Competing interests and funding: We have no conflicts of interest to disclose and no funding to report.

Abbreviations

Consolidated criteria for reporting qualitative research

Doctor medicinae

Doctor medicinae dentariae

Doctor scientiarum humanarum

Medical Doctor

Lewin S, Glenton C. Are we entering a new era for qualitative research? Using qualitative evidence to support guidance and guideline development by the World Health Organization. Int J Equity Health. 2018;17(1):126.

Article   Google Scholar  

Sale JEM, Thielke S. Qualitative research is a fundamental scientific process. J Clin Epidemiol. 2018;102:129–33.

Salmon P, Young B. Qualitative methods can test and challenge what we think we know about clinical communication – if they are not too constrained by methodological ‘brands’. Patient Educ Couns. 2018;101(9):1515–7.

Tugwell P, et al. Systematic Review Qualitative Methods Series reflect the increasing maturity in qualitative methods. J Clin Epidemiol. 2018;97:vii–viii.

Sibeoni J, et al. A specific method for qualitative medical research: the IPSE (inductive process to analyze the structure of lived experience) approach. BMC Med Res Methodol. 2020;20(1):216.

Dicicco-Bloom B, Crabtree BF. The qualitative research interview. Med Educ. 2006;40(4):314–21.

Wilkinson S. Focus groups in health research: exploring the meanings of health and illness. J Health Psychol. 1998;3(3):329–48.

Article   CAS   Google Scholar  

Vindrola-Padros C, Vindrola-Padros B. Quick and dirty? A systematic review of the use of rapid ethnographies in healthcare organisation and delivery. BMJ Qual Saf. 2018;27(4):321–30.

Catchpole K, et al. Framework for direct observation of performance and safety in healthcare. BMJ Qual Saf. 2017;26(12):1015–21.

Ullrich C, Oetting-Roß C. Qualitative Beobachtung als Methoden in den Gesundheitswissenschaften. In: Niederberger M, Finne E, editors. Forschungsmethoden in der Gesundheitsförderung und Prävention. Heidelberg: Springer; 2020.

Google Scholar  

Bowen Glenn A. Document analysis as a qualitative research method. Qual Res J. 2009;9(2):27–40.

Emerson, R.M., R.I. Fretz, and L.L. Shaw, Writing ethnographic fieldnotes. [2nd publ.] ed. Chicago guides to writing, editing and publishing. 2011. Chicago [u.a.]: Univ. of Chicago Pr.

Dai S, et al. Evaluation of the reporting quality of observational studies in master of public health dissertations in China. BMC Med Res Methodol. 2020;20(1):230.

Bundesamt S. Anzahl universitärer Abschlüsse in der human- und Zahnmedizin in Deutschland nach Prüfungsart im Jahr 2018; 2019.

Fakultätentag M. Positionspapier Vermittlung von Wissenschaftskompetenz im Medizinstudium; 2017.

Diez C, Arkenau C, Meyer-Wentrup F. Bearbeitung und Betreuungsqualität medizinischer Dissertationen an der Medizinischen Fakultät Würzburg aus der Sicht von Promovenden des 5. Und 6. Studienjahres. Gesundheitswesen. 2002;64(07):437–43.

Education, W.F.o.M., Basic Medical Eduation: WFME Global Standards for Quality Improvement: Basic Medical Education. 2015.

Pabst R, Park DH, Paulmann V. Die promotion in der Medizin ist besser als ihr Ruf. Dtsch Med Wochenschr. 2012;137(45):2311–5.

Cursiefen C, Altunbas A. Contribution of medical student research to the Medline-indexed publications of a German medical faculty. Med Educ. 1998;32(4):439–40.

Ziemann E, Oestmann J-W. Publikationen von Doktoranden 1998–2008. Dtsch Arztebl Int. 2012;109(18):333–7.

PubMed   PubMed Central   Google Scholar  

BMBF, Masterplan Medizinstudim 2020 . 2017.

Empfehlungen zur Weiterentwicklung des Medizinstudiums in Deutschland auf Grundlage einer Bestandsaufnahme der humanmedizinischen Modellstudiengänge (Drs. 4017–14), Juli 2014, G.C.o.S.a. Humanities., Editor. 2014.

Mbuagbaw L, et al. A tutorial on methodological studies: the what, when, how and why. BMC Med Res Methodol. 2020;20(1):226.

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57.

O’Brien BC, et al. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51.

Mayring, P., Qualitative Content Analysis. 2000. 2000. 1(2).

Sielk M, Brockmann S, Wilm S. Qualitative Forschung - Hineindeuten in oder Abbilden von Wirklichkeit? Z Allg Med. 2004;80(08):334–42.

Jaye C. Doing qualitative research in general practice: methodological utility and engagement. Fam Pract. 2002;19(5):557–62.

Gale NK, et al. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(1):117.

Barbour RS. Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? BMJ. 2001;322(7294):1115–7.

Vasileiou K, et al. Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Med Res Methodol. 2018;18(1):148.

Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies:guided by information power. Qual Health Res. 2016;26(13):1753–60.

Hennink MM, Kaiser BN, Weber MB. What influences saturation? Estimating sample sizes in focus group research. Qual Health Res. 2019;29(10):1483–96.

Ratte A, Drees S, Schmidt-Ott T. The importance of scientific competencies in German medical curricula - the student perspective. BMC Med Educ. 2018;18(1):146.

Thimme R, et al. Strukturierte Karrierewege in der Universitätsmedizin. Dtsch Med Wochenschr. 2019;144(07):489–93.

Zenz M, Zenz J, Grieger M. Erwähnung des Ethikvotums in deutschen medizinischen Dissertationen und Publikationen. Bundesgesundheitsbl Gesundheitsforsch Gesundheitsschutz. 2018;61(7):857–63.

Malterud K, Hamberg K, Reventlow S. Qualitative methods in PhD theses from general practice in Scandinavia. Scand J Prim Health Care. 2017;35(4):309–12.

Cohen JF, et al. STARD for Abstracts: essential items for reporting diagnostic accuracy studies in journal or conference abstracts. BMJ. 2017;358:j3751.

Hopewell S, et al. CONSORT for reporting randomized controlled trials in journal and conference abstracts: explanation and elaboration. PLoS Med. 2008;5(1):e20.

Collins GS, et al. Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement. Ann Intern Med. 2015;162(1):55–63.

Bougioukas KI, et al. Reporting guidelines on how to write a complete and transparent abstract for overviews of systematic reviews of health care interventions. J Clin Epidemiol. 2019;106:70–9.

Download references

Acknowledgements

We would like to thank Laura Svensson for assisting in reviewing the abstracts and data extraction. In addition, we would like to thank the reviewers for their thorough review and constructive comments.

Open Access funding enabled and organized by Projekt DEAL.

Author information

Authors and affiliations.

Department of General Practice and Health Services Research, University of Heidelberg Hospital, INF 130.3, 69120, Heidelberg, Germany

Charlotte Ullrich, Anna Stürmlinger, Michel Wensing & Katja Krug

You can also search for this author in PubMed   Google Scholar

Contributions

CU and KK conceived the idea for this manuscript. CU, KK and AS reviewed, extracted and analyzed the data. KK led the data analysis. CU wrote the first draft of the manuscript. MW provided substantial comments at different stages of the manuscript. CU, KK and MW critically revised the manuscript. All authors read and approved the manuscript for submission.

Corresponding author

Correspondence to Charlotte Ullrich .

Ethics declarations

Ethics approval and consent to participate.

Not applicable. In accordance with the scope and design of this study no formal study protocol was written.

Consent for publication

Not applicable.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Ullrich, C., Stürmlinger, A., Wensing, M. et al. Qualitative research methods in medical dissertations: an observational methodological study on prevalence and reporting quality of dissertation abstracts in a German university. BMC Med Res Methodol 20 , 301 (2020). https://doi.org/10.1186/s12874-020-01186-6

Download citation

Received : 01 October 2020

Accepted : 02 December 2020

Published : 10 December 2020

DOI : https://doi.org/10.1186/s12874-020-01186-6

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Medical dissertation
• Higher education
• Qualitative research
• Methodological study

BMC Medical Research Methodology

ISSN: 1471-2288

• General enquiries: [email protected]

• Harvard Medical School

HMS Theses and Dissertations

• Communities & Collections
• By Issue Date
• FAS Department
• Quick submit
• Waiver Generator
• Lin, Yan (2)
• Aboelsaad, Iman Ahmed Fathalla (1)
• Acar, Utkucan (1)
• Acharya, Shree (1)
• Afari, Henrietta (1)
• Afinogenova, Yuliya (1)
• Agrawal, Vishesh (1)
• Akabane, Andressa Lumi (1)
• Akinwunmi, Babatunde Olayode (1)
• Al Qureshah, Fahd (1)
• ... View More
• Medicine (79)
• Immunology (60)
• Education (14)
• Neurosciences (14)
• Health sciences (13)
• Oncology (12)
• Bioinformatics (10)
• Biology (8)
• Health education (6)
• Medical Personnel (6)
• Scholarly Project (2)
• Honors in a Special Field (1)
• Master of Medical Sciences in Biomedical Informatics (1)
• Master’s Program in Clinical Investigation (1)
• DASH Stories
• Accessibility
• COVID-related Research
• Terms of Use
• Privacy Policy
• By Collections
• By Departments

Recent Submissions

Adaptive expertise in plastic surgery: the plastic surgeon experience of developing, maintaining and teaching adaptive expertise , klf6 mediates de novo ornithine synthesis and polyamine production in pancreatic ductal adenocarcinoma , integration of decision support algorithm and genomic mutational analysis for enhanced diagnosis and characterization of hematological diseases .

Edinburgh Research Archive

•   ERA Home
• Edinburgh Medical School

Edinburgh Medical School thesis and dissertation collection

By Issue Date Authors Titles Subjects Publication Type Sponsor Supervisors

Search within this Collection:

Edinburgh Medical School is one of two schools at the College of Medicine and Veterinary Medicine at the University of Edinburgh. The Edinburgh Medical School integrates research and teaching across our three Deaneries: Biomedical Sciences, Clinical Sciences and Molecular,Genetic and Population Health Sciences.

Recent Submissions

Phenotype of newly generated neurons following spinal cord injury in zebrafish , exploration of relationships between life course measures of socioeconomic status and structural brain changes linked with older life cognitive decline , high resolution analysis of the tumour microenvironment of high grade serous ovarian cancer (hgsoc) using single cell transcriptomics and quantitative histopathological examination , complications of portal hypertension: clinical studies , imaging of abdominal aortic aneurysm disease activity and implications for endovascular aneurysm repair , hallmarks of cotranslational protein complex assembly and its relationship with the dominant-negative effect , optimising islet transplantation therapy for the treatment of type 1 diabetes by targeting the liver niche with etanercept-loaded microparticles to promote the long term function of islets , developing a systematic, data-driven framework to identify, evaluate, and prioritise candidate drugs for clinical trials in motor neuron disease , investigating an arginase 1⁺ monocyte- macrophage population in driving fibrosis in chronic kidney disease. , in vivo investigation of component-specific functions of the hippo pathway , prevalence of female infertility in the uk armed forces , understanding colorectal cancer risk loci that alter transcriptional dynamics , behaviour change intervention for smokeless tobacco (st) cessation delivered by dentists in a dental setting: a feasibility study , dna methylation & its regulation in colorectal tumours , lesion reversibility in small vessel disease: understanding changes contributing to vascular dementia , effect of autologous macrophage therapy in cirrhosis in response to individual immune reparative pathways: developing a novel therapy , computational techniques to interpret the neural code underlying complex cognitive processes , identifying genomic and phenotypic risks factors for the clinical progression of depressive symptoms , investigating the essential extracellular invadolysin metalloprotease , defining novel regulators of inflammatory signalling in pancreatic cancer .

•   Home

Submission Guidelines for Morningside Dissertations and Theses

Benefits to umass chan students of archiving your thesis/dissertation in the escholarship@umasschan repository, requirements prior to submission, before you begin the online submission process, how to submit, what happens next, public access, embargoes, licenses, and subsequent publishing, digital object identifiers (dois), sharing research data publicly, publication and post-publication edits, repository citation and download metrics, removal of content.

• Immediate exposure through Google and other search engines to maximize readership and impact (citations) of your scholarship
• Download statistics are available
• Permanent link, DOI and citation for inclusion on your CV
• Students must follow the graduate school's preparation guidelines for doctoral dissertations and master's theses to ensure that formatting is correct, no required pages are missing, and their thesis/dissertation is properly converted to PDF format. Please make your document is as accessible to users with disabilities as possible. This ensures ease of use and the broadest possible readership for your work. See our accessibility guidelines for authors .
• The student should ensure that their thesis/dissertation is free of errors. Once the graduate school has posted the thesis/dissertation on eScholarship@UMassChan, corrections cannot be made unless the student submits an official request to the Dean of the graduate school.
• The Dissertation Defense Outcome (BBS08) form or the Master's Thesis Outcome (MSCI08) form must be completed and submitted before beginning the electronic submission process in eScholarship@UMassChan.
• Students and their thesis advisor should discuss and reach a mutual agreement regarding which embargo option and which license are appropriate. See Public access, embargoes, licenses, and subsequent publishing for guidelines and a full explanation of options.
• The GSBS19 eScholarship Permission Form must be filled out and signed electronically by the student and the student’s advisor(s). This form certifies that the manuscript is complete and has been approved by the student’s advisory committee, and designates the student’s selections for embargo and re-use rights. Preview GSBS19 form
• Students are required to register for an ORCID and enter their ORCID ID on the GSBS19 eScholarship Permission Form. ORCIDs are unique author identifiers for researchers that are becoming integrated into research workflows. Your ORCID iD ensures you get credit for your work throughout your career and is increasingly a requirement for publication and funding. Registration is free and takes 30 seconds.

Before you begin the online submission process, please be sure you have the following items ready:

• Full text of your final, approved thesis/dissertation in PDF format
• Name of Thesis Advisor(s)
• Your GSBS19 eScholarship Permission Form must first be completed and electronically signed by you and your thesis advisor(s)
• Supplemental files to be displayed on the web page with your thesis/dissertation (e.g. data sets, video clips, sound files), if applicable
• Log into eScholarship@UMassChan using your UMass Chan email address and password
• Click the "Submissions" link in the left sidebar under "My Account"
• Click on "start a new submission"
• Select this collection: UMass Chan Student Research and Publications > Morningside Graduate School of Biomedical Sciences > Morningside GSBS Dissertations and Theses
• Fill in submission form and submit
• NOTE: The Upload File(s) step on the submission form includes an Embargo field. Select a date based on the embargo option you and your advisor chose on your eScholarship permission form. For example, for a 1-year embargo, select a date one year from the submission date. Skip this field if you are not requesting an embargo.
• After reviewing the submission, the graduate school or the library will contact the student for any revisions necessary.
• The library will post the thesis/dissertation in eScholarship@UMassChan within 1-2 weeks of acceptance, with or without an embargo and Creative Commons license as specified on the permission form.
• The student will receive an email with a persistent link to the submission when it is posted.

Students retain ownership of the copyright for the content of their thesis or dissertation, including the right to use all or part of the content in future works. Students are free to register the copyright to their work with the U.S. Copyright Office.

Students are solely responsible for obtaining the rights to use any third-party copyrighted materials, allowing electronic distribution, prior to submission.

The full text of theses and dissertations from the graduate school are made publicly available in UMass Chan Medical School’s repository, Scholarship@UMassChan, unless the student has elected to postpone online access to the full text for a specified time (this is known as an embargo). Students may choose from the following embargo options: no embargo; 6 months; 1 year; 2 years and indicate their choice on the GSBS19 eScholarship Permission Form.

There is a record of each embargoed thesis/dissertation in eScholarship@UMassChan that displays the author name, title, abstract, publication year, GSBS program, advisor, and department affiliations. The record also shows when the embargo will expire. Only the administrators of eScholarship@UMassChan can access the full text of the thesis/dissertation before the embargo expiration date.

Possible reasons to consider an embargo:

• The student is applying for a patent on an invention or procedure documented in the thesis/dissertation and does not wish to make the contents public until the patent application has been filed
• The thesis/dissertation contains sensitive and/or classified information
• Immediate release of the thesis/dissertation may impact an existing or potential publishing agreement

Students often wonder if including unpublished data in a thesis or dissertation precludes later publication in peer-reviewed journals. As publisher policies on previous or duplicate publication vary, it is best to check with the publisher in question. Many publishers include this information on their websites. For example, Nature will consider submissions of material previously published in a thesis or dissertation. The MIT Libraries have compiled a helpful chart summarizing the policies of some publishers. UMass Chan students have the option of utilizing the embargo feature so that the full text of their dissertation is not publicly available while they are in the process of submitting manuscripts for publication in journals.

If students do not request an embargo, or following the expiration of an embargo, the thesis/dissertation will be made publicly available in eScholarship@UMassChan and marked with “All Rights Reserved” or a Creative Commons license as specified by the student.

Creative Commons (CC) licenses are popular tools to facilitate knowledge sharing and creative innovation that copyright holders can apply to their works to indicate how they would like their materials to be used. Those who want to make their work available to the public for limited kinds of uses while preserving their copyright may want to consider using CC licenses. Students have three options to choose from and should select the option that best meets their goals:

• Creative Commons Attribution (CC BY) : This license lets others distribute, remix, tweak, and build upon your work, even commercially, as long as they credit you for the original creation. This is the most accommodating of licenses offered. Recommended for maximum dissemination and use of licensed materials.
• Creative Commons Attribution-NonCommercial (CC BY-NC) : This license lets others remix, tweak, and build upon your work non-commercially, and although their new works must also acknowledge you and be non-commercial, they don’t have to license their derivative works on the same terms.
• Copyright is held by the author, with all rights reserved: This phrase indicates that the student, as the copyright holder, reserves, or holds for their own use, all the rights provided by copyright law, and that nothing may be done with a copyrighted work without their explicit permission.

Students and their thesis advisors should discuss and reach a mutual agreement regarding which embargo option and which Creative Commons license are appropriate. Conflicts between the wishes of the student and the advisor should be resolved before the student completes the GSBS19 eScholarship Permission Form .

Students can direct questions about public access, copyright, embargoes, and subsequent publication to the library .

Students are required to register for an ORCID and enter their ORCID ID on the GSBS19 eScholarship Permission Form. ORCIDs are unique author identifiers for researchers that are becoming integrated into research workflows. Your ORCID iD ensures you get credit for your work throughout your career and is increasingly a requirement for publication and funding. Registration is free and takes 30 seconds.

Theses and dissertations deposited in eScholarship@UMassChan are assigned a DOI (Digital Object Identifier). DOIs are permanent unique identifiers assigned to publications, data, and other scholarly products that make it easier for them to be discovered, cited, and credited.

Students have many options for publicly sharing research data, including government-sponsored repositories such as GenBank or GEO, disciplinary repositories, third-party repositories, and established campus resources such as LabArchives and UMass Chan's institutional repository, eScholarship@UMassChan .

In thesis and dissertation manuscripts, students can include links to research data that has been permanently shared publicly, whether through deposit to a repository or published with a DOI through LabArchives. DOIs are permanent unique identifiers assigned to publications, data, and other scholarly products that make it easier for data to be discovered, cited, and credited. It is recommended that students use a DOI, if available, to link to research data from within their theses and dissertations. Both LabArchives and eScholarship@UMassChan have the ability to assign DOIs to datasets stored and shared with the software.

Students also have the option to upload research data as supplemental files when they are submitting their thesis or dissertation to eScholarship@UMassChan. Data files are displayed on the web page with the thesis or dissertation and download statistics are available.

In all cases, students should make sure that permanent, public data sharing is appropriate. Data should be documented so that it is easier to understand. Good data management practices should be followed, including using standard data and file formats, good null values, and basic quality control (see Ten Simple Rules for the Care and Feeding of Scientific Data ).

Theses and dissertations are published exactly as they are submitted. They are not edited, typeset, or retyped by the graduate school or the library. Therefore, the document’s appearance when it is accessed or printed is entirely the responsibility of the student. The student must assume responsibility for: preparing the document according to the graduate school guidelines for preparation of theses and dissertations; converting the document into Adobe PDF format; checking the document for appearance; and submitting the final, approved PDF document to eScholarship@UMassChan.

Once the graduate school has posted the thesis/dissertation on eScholarship@UMassChan, corrections or retractions cannot be made unless the student submits an official request to the Dean of the graduate school. Since this is the version of record, the full-text cannot simply be swapped out. Changes can be made to the metadata (descriptive information about the thesis/dissertation) but not to the full text. Upon graduate school approval, students will be allowed to upload another version which will display as an additional file, or to submit revised supplemental data as an additional file. The record will be amended to describe the actions/correction.

As the thesis/dissertation is the student’s intellectual property, only the student can initiate a cancellation or an extension of an approved embargo, or a change to a Creative Commons license, by submitting an official request to the Dean of the graduate school. The request should include the reason for the requested change and the desired length of time to extend the embargo.

Posting your thesis/dissertation in eScholarship@UMassChan provides a permanent link and DOI that you can include on a resume or CV. A citation can be exported from the main page of each thesis/dissertation for EndNote, RefWorks, and other formats. Theses and dissertations are available immediately in Google, Google Scholar, and other search engines to maximize readership and impact of your scholarship. The number of full text downloads is updated daily. The download count is available from the thesis/dissertation main page by clicking "Show Statistical Information".

Binding of theses or dissertations is no longer a UMass Chan requirement by the graduate school or the library. The electronic versions will be the version of record. If the student’s department/committee chair requires a print copy, or the student wants print copies, binding arrangements and fees are the sole responsibility of the student. Interested students can consult the graduate school for a recommendation for a local bindery. If you have further questions, please contact the graduate school at [email protected] .

The full text of a work will generally be removed from eScholarship@UMassChan only for reasons such as unethical/ unsound science, plagiarism, copyright infringement, IRB non-compliance and/or violation of the Licensing Agreement. Removal requests should be sent to the GSBS Dean and should include the reason for removal. If the work is removed, a record describing the original version of the paper will always remain on the site at the same URL.

Export search results

The export option will allow you to export the current search results of the entered query to a file. Different formats are available for download. To export the items, click on the button corresponding with the preferred download format.

By default, clicking on the export buttons will result in a download of the allowed maximum amount of items.

To select a subset of the search results, click "Selective Export" button and make a selection of the items you want to export. The amount of items that can be exported at once is similarly restricted as the full export.

After making a selection, click one of the export format buttons. The amount of items that will be exported is indicated in the bubble next to export format.

Home > MUSC Theses and Dissertations

MUSC Theses and Dissertations

Theses/dissertations from 2024 2024.

Next Generation Human Cardiac Organoids: Modeling Inflammatory Diseases and Engineering their Protection in vivo , Dimitrios Chrisovalantou Arhontoulis

Characteristics and Patterns of Diagnoses for Patients Admitted from and Discharged to Court or Law Enforcement in the State of Florida , Christopher Bridgeman and Christopher Bridgeman

Estradiol Signaling Improves Extinction Memory Recall to Combat Cue-Induced Heroin Relapse in Rats , Jordan S. Carter

Financial Implications Associated With Laboratories Performing Laboratory Developed Tests For Medicare and Commercial Patients , Summer Hartig

Exploring Patterns in Worksite Healthcare: An Exploratory Analysis of Worksite Healthcare Utilization and Costs , Patrick Howell

The Regulation of BRD4 in Transcription and DNA Repair , Baicheng Lin

Comparative Analysis of Inpatient and Outpatient Total Hip Arthroplasty: Cost, Rehabilitation, and Complexity , Kam Maghazehe

The Impact of Covid-19 on the Utilization of Early Magnetic Resonance Imaging (eMRI) in the Assessment of Acute Uncomplicated Low Back Pain (LBP) and the Subsequent Effect on Health Care Service Utilization and Patient Outcomes , Kimberly Radcliffe

Opportunistic Pathogen Porphyromonas gingivalis Targets the LC3B-ceramide Complex and Mediates Lethal Mitophagy Resistance in Oral Squamous Cell Carcinoma , Megan Sheridan

Therapeutic Inhibition of Complement Component 3 in Spontaneous Osteoarthritis , Jen Xu

Theses/Dissertations from 2023 2023

Resilience Culture in the Healthcare Team During COVID-19 , John Ambrose

Trends in Primary Care Visits and Diabetes Control for Type 2 Diabetics before and during the COVID-19 Pandemic , Carole Berini

Simultaneous Inhibition of ErbB3 and Calmodulin-Mediated Signaling Effectively Inhibits Malignant Peripheral Nerve Sheath Tumor Proliferation and Survival , Laurel Black

Increased Physician Literacy as an Intervention to Improve Value-Based Care and Reduce Cost in the Surgical Setting , Melissa Boyles

Role of PRMT5 in ULK1-Mediated Autophagy and Breast Cancer Therapy , Charles Brobbey

The Association Between Race and Rurality on Maternal and Infant Outcomes in North Carolina , Ebony Burns

Antibiotic-Induced Gut Dysbiosis During Adolescence Dysregulates Metabolism and Skeletal Maturation , Matthew Carson

Food Deserts Impact on Hospital Admissions in Malnourished Patients Residing in Florida , Joshua Cartwright

Personalization and Optimization of Noninvasive Brain Stimulation for Transdiagnostic Applications , Kevin Caulfield

Activity Dynamics of the Nucleus Accumbens Neurons During Natural and Drug Reward Seeking , Reda M. Chalhoub

MEF2C Hypofunction in GABAergic Cells Alters Sociability and Prefrontal Cortex Inhibitory Synaptic Transmission in a Sex-dependent Manner , Yongjoo Cho

Assessing the Involvement of Projections from the Prelimbic Prefrontal Cortex to the Paraventricular Nucleus of the Thalamus in Cocaine Withdrawal-Induced Anxiety , Clinton Coelho

Time is Brain: How a Descriptive Analysis of Telestroke Metrics Can Improve Program Performance , Christopher Cordero

The Role of Complement in Stroke and Traumatic Brain Injury , Christine Couch

What Are the Barriers to Midwife Service Utilization Among Low-Risk Pregnant Women in Florida? , Ileana Cruz

Page 1 of 34

• Collections
• Disciplines

Advanced Search

• Notify me via email or RSS

Author Corner

• Submission Guidelines
• Submit Research

Home | About | FAQ | My Account | Accessibility Statement

Privacy Copyright

Home > MAHE Student Work > KMCMLR

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

Advanced Search

• Notify me via email or RSS
• Institutions
• Disciplines

Author Corner

Home | About | FAQ | My Account | Accessibility Statement

Privacy Copyright

Publication types

• Case Reports

Search Icon

Events See all →

2024 models of excellence.

4:00 p.m. - 6:30 p.m.

Penn Museum, 3260 South St.

Difficult Grace

Annenberg Center for the Performing Arts, 3680 Walnut St.

Earth Week 2024

This is a campuswide week of events, lectures, and volunteer opportunities designed to educate and inspire action related to environmental justice, climate, and nature-based solutions. This year’s theme is Restore & Regenerate.

Various locations

Take Our Children to Work Day

Arts, Humanities, & Social Sciences

Two centuries old, a handwritten record of medical education

Penn libraries is part of a multi-institution-funded project to digitize materials from early medical education. more than 1,000 penn dissertations are now online, with the earliest dating from 1807..

The script in black ink on cream cotton rag paper is filled with flourishes on the title page of the dissertation by University of Pennsylvania medical student Americus Vesuvius Payne, dated March 30, 1820. In the corner, in pencil, is the address, No. 201 Walnut.

Photographed at the Penn Libraries earlier this summer, it is one of more than 60,000 pages in more than 1,000 Penn medical student dissertations from the early 1800s that have been digitized over the past two years. The dissertations are available to the public free of charge through the Libraries online catalogue .

Penn opened its School of Medicine , the nation’s first, in 1765. The Hospital of the University of Pennsylvania was established in 1874 as the nation’s first teaching hospital. Until just the Civil War, Penn’s medical school required students to write dissertations as part of the degree process, and those submitted to the College are in the Libraries collection.

“We are hoping there will be a lot of interest in these dissertations, as you can get a sense for early medical education. And you can see intersections, for example, of medical education with gender and race,” says Mitch Fraas , senior curator, Kislak Center for Special Collections, Rare Books and Manuscripts . “Having a targeted project on material this early is unusual.”

Research value

A Visiting Fellow since 2019 with the Penn Medicine and the Afterlives of Slavery project, Christopher D.E. Willoughby has read through nearly 2,000 of Penn’s medical dissertations from 1807 to 1861. 

What he discovered “became the backbone” of a book he just completed, “Masters of Health: Racial Science and Slavery in U.S. Medical School,” now under contract with the University of North Carolina Press. Willoughby also used the dissertations for research on his own Ph.D. dissertation, “Pedagogies of the Black Body: Race and Medical Education in the Antebellum United States” for his doctoral degree from Tulane University in 2016.

They can help us take the pulse of medical education in a lot of areas, like race, gender, medical history, and learn how medical students learned and how they planned to apply it to their practice. Christopher D.E. Willoughby, visiting fellow with the Penn Medicine and the Afterlives of Slavery project

Penn, he says, has more of these 19th century dissertations than any other medical school in the country. “With the sheer volume of the dissertations at Penn you can take the pulse of medical education,” Willoughby says. “You really get a sense of what they were teaching and how the students were processing it.”

The digitized dissertations, which allow for computerized searches by keyword, are much more accessible and easier to manage than paging through the original volumes as he did, looking for interesting titles. Researchers can learn “what a more average physician is thinking and trace that over this 50-year period,” written by people whose work would not usually have been published, he says.

“Their mundaneness is what makes them special,” Willoughby says. “They provide interesting, and in some cases disturbing, anecdotes about everyday medical complaints, as well as what doctors thought.”

Digitizing details

The digitization project started in April two years ago, and the scans were completed in June, Fraas says. More than 1,000 dissertations are now online, and all included in the project are expected to be uploaded and available this month. The project was funded by a $500,000 Council on Library & information Resources (CLIR) grant to a consortium of Philadelphia libraries which house early medical materials, including the College of Physicians of Philadelphia and Thomas Jefferson University .

At some point in the 20th century the dissertations were bound together, each with a plain, black hardback book cover, Fraas says. Each of the bound volumes has 20 to 30 dissertations and total about 800 pages each. The median number of pages per dissertation is 25 to 30, but there are a number that are much shorter, and a few “really prolific” ones that are more than 200 pages, Fraas says.

The CLIR-funded project includes 54 volumes and cover all surviving theses from before 1829, with the earliest dating from 1807 and the majority written in the 1820s. There are many more dissertations on the Kislak Center’s shelves, at least five times the amount they have just digitized, Fraas says, while standing in the stacks in front of the rows of black-covered volumes. The Libraries also has hundreds of volumes of lecture notes taken by medical students.

It takes about two days to digitize one of the bound volumes, says P.J. Smalley , digital camera operator in the Libraries’ Schoenberg Center for Electronic Text & Image. They photograph every page front and back even if it appears to be blank. “The only way you're going to capture the objects and do it right is to do the whole thing, every page,” Fraas says.

The paper is made of cotton rag, not of wood pulp like modern paper. “Sometimes we’ll shoot stuff from the 20th century that will be way worse shape than something that’s from the 1600s,” Smalley says. “These are in really good shape.”

They are “creating a surrogate,” digital files that may or may not outlast the original, says Jordan Rothschild , digital camera operator, while preparing one of the bound volumes on the glass. The images are a very high resolution and color-corrected for accuracy, he says, “reproducing an image of an item as faithfully as we possibly can, not making it ‘look pretty’ or altering in any way.”

Cataloguing and keywords

When the manuscripts were bound together, they were grouped by topic. Many of the topics are recognizable, like cholera and constipation and croup, but some of the dissertation topics use medical terminology from the early 19th century that are not used today.

Elsa Varela , special collections cataloging librarian, has reviewed every manuscript to catalogue characteristics for database searches, like the date, the author, title, date, and subject. While cataloguing the manuscripts Varela includes both the original medical citation and also an interpretation with modern terminology.

“It’s important because those subject headings and keywords make things more findable,” she says. “A lot of titles were vague, like the effects of cold, or described in terms that are no longer being used. Using a standardized Library of Congress subject heading is especially important.”

The team conducting the digitizing within the Schoenberg Center for Electronic Text & Image shoot more than 300,000 images a year in their workspace in the basement of the Van Pelt Library, says Smalley. The digitizing team was not on campus due to pandemic restrictions starting in March 2020. They returned, but at limited capacity, starting in August 2020 and picked up the work once again.

Varela continued the cataloguing work from her home using digitized images instead of pulling the volume from the shelf and going through each dissertation by hand. She was working on Volume 34 when the pandemic restrictions went into effect, and there were 20 more volumes to go. “In a way it is better to catalog from the digitized dissertations. It allows you to zoom in on things,” she says. “Sometimes the handwriting is hard to read and it does help me identify names.”

The handwriting varies, of course, with some so beautifully executed that Fraas and Varela speculate some students hired scribes to write out the final manuscript. Some dissertations have notes written in the margins or on the backs of pages. The cover pages can be elaborate or plain or even include the address of the author, like Americus Payne’s, “ An Inaugural Dissertation on Cholera Infantum .”

“It was interesting to look at these different handwritings and different styles,” Varela says. “I wondered if these were farmed out, just like hiring someone to type up a term paper. Some of the handwriting is so lovely. It was nice to see.”

Dissertation details

Although she didn’t read each one, she did examine some that piqued her interest. “It was really interesting during these times to be reading them because we are all thinking about health,” she says. 

One of the dissertations was included in the Penn & Slavery project: “ Observations on The manner of Living and Diseases of the Slaves on the Wateree River ” by William L. McCaa of Camden, South Carolina, written in 1822 and presented as an inaugural essay to Penn’s medicine faculty. “On the last page the author tells of a case in which an enslaved woman delivered her own child in the field,” Varela says. “I added the subject heading ‘discrimination in medical care’ as a way to highlight the author’s bias.”

Others she highlights as interesting include “ Essay on Menstruation ” dated 1829 by Joseph M. Urquiola, a native of Trinidad de Cuba, who she says was the first Latin American graduate of Penn. And “ An Inaugural Dissertation on Lead and its Preparations ” dated 1824 by William Wetherill of Philadelphia, because the Libraries also holds the papers of the Wetherill & Son’s white lead company. The Libraries has a portrait of the author of “ A Treatise on Spina Bifida with two cases of its treatment ” written in 1829 by Josiah Barnes of Litchfield, Connecticut.

Fraas says some of the dissertations are “pretty lugubrious,” noting that some of those that he read were philosophical speculation. “Some of them are more based in observation, some are sort of last-minute, made-up things, and some of them are more serious works of research,” Fraas says. “It is a different kind of medical education than people would know.”

Willoughby says these dissertations are “more rote, derivative products,” not like the dissertations of today that have original research. “It’s much more akin to a senior thesis,” he says.

• Accessing an artistic archive
• Newly digitized Marian Anderson collection now accessible online
• Penn brings Philadelphia’s rare manuscripts to the world
• Penn Libraries expands digital collections, online platforms, and expert support
• Unexpected finds bring fresh excitement to the archives

In the 18th century when Penn’s medical school was founded, physicians were mostly trained through apprenticeships, and the few elite who went to medical school wrote dissertations in Latin, Willoughby says. As medical schools became established, the enrollment grew and those students did not usually know Latin, he says, so they were written in English. After the Civil War most medical doctors went to medical school, and it was decided the dissertations were not valuable, he says.

But they have value now. “They can help us take the pulse of medical education in a lot of areas, like race, gender, medical history, and learn how medical students learned and how they planned to apply it to their practice,” he says. “These medical theses allow us to see what the average physician thought.” 

Willoughby says he can trace the origins and growth of racism in the practice of medicine through the dissertations, and also gain insight into the lives of impoverished and enslaved people by their ailments and injuries. “I’ll be citing medical dissertations from Penn until I retire, or change research subjects,” he says. “I think they have a lot to tell.”

Mitch Fraas is director of special collections & research services and a senior curator for special collections at the Kislak Center for Special Collections, Rare Books and Manuscripts at the University of Pennsylvania Libraries.

Jordan Rothschild is digital camera operator in the Schoenberg Center for Electronic Text & Image at the University of Pennsylvania Libraries.

P.J. Smalley is digital camera operator in the Schoenberg Center for Electronic Text & Image at the University of Pennsylvania Libraries.

Elsa Varela is special collections cataloging librarian at the University of Pennsylvania Libraries.

Christopher D.E. Willoughby has been a visiting fellow with the Penn Medicine and the Afterlives of Slavery project since 2019. In the fall he will be the Molina Fellow in the History of Medicine & Allied Sciences at The Huntington Library and a visiting scholar at the Charles Warren Center for Studies in American History at Harvard University.

Penn celebrates operation and benefits of largest solar power project in Pennsylvania

‘The Illuminated Body’ fuses color, light, and sound

A new Arthur Ross Gallery exhibition of work by artist Barbara Earl Thomas features cut-paper portraits reminiscent of stained glass and an immersive installation constructed with intricately cut material lit from behind.

Campus & Community

25 years of ‘LOVE’

The iconic sculpture by pop artist Robert Indiana arrived on campus in 1999 and soon became a natural place to come together.

Health Sciences

Two-and-a-half decades of research in Malawi

As the country’s life expectancy has risen, the Malawi Longitudinal Study of Families and Health has shifted its current and future research to aging.

Science & Technology

In hot water: Coral resilience in the face of climate change

Over a decade, researchers from Penn studied coral species in Hawaii to better understand their adaptability to the effects of climate change.

Loading metrics

Open Access

Peer-reviewed

Research Article

The bidirectional association between premenstrual disorders and perinatal depression: A nationwide register-based study from Sweden

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected] (QY); [email protected] (DL)

Affiliation Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden

Roles Writing – review & editing

Affiliations Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, United States of America, Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, United States of America

Roles Methodology, Supervision, Validation, Writing – review & editing

Affiliation Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden

Roles Resources, Supervision, Writing – review & editing

Roles Data curation, Methodology, Resources, Writing – review & editing

Roles Conceptualization, Funding acquisition, Methodology, Project administration, Resources, Supervision, Writing – review & editing

Affiliations Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden, Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America, Center of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland

Roles Conceptualization, Data curation, Funding acquisition, Methodology, Project administration, Resources, Software, Supervision, Validation, Writing – review & editing

• Qian Yang, 
• Emma Bränn, 
• Elizabeth R. Bertone- Johnson, 
• Arvid Sjölander, 
• Fang Fang, 
• Anna Sara Oberg, 
• Unnur A. Valdimarsdóttir, 

• Published: March 28, 2024
• https://doi.org/10.1371/journal.pmed.1004363
• Peer Review
• Reader Comments

Premenstrual disorders (PMDs) and perinatal depression (PND) share symptomology and the timing of symptoms of both conditions coincide with natural hormonal fluctuations, which may indicate a shared etiology. Yet, there is a notable absence of prospective data on the potential bidirectional association between these conditions, which is crucial for guiding clinical management. Using the Swedish nationwide registers with prospectively collected data, we aimed to investigate the bidirectional association between PMDs and PND.

Methods and findings

With 1,803,309 singleton pregnancies of 1,041,419 women recorded in the Swedish Medical Birth Register during 2001 to 2018, we conducted a nested case-control study to examine the risk of PND following PMDs, which is equivalent to a cohort study, and transitioned that design into a matched cohort study with onward follow-up to simulate a prospective study design and examine the risk of PMDs after PND (within the same study population). Incident PND and PMDs were identified through clinical diagnoses or prescribed medications. We randomly selected 10 pregnant women without PND, individually matched to each PND case on maternal age and calendar year using incidence density sampling (N: 84,949: 849,482). We (1) calculated odds ratio (OR) and 95% confidence intervals (CIs) of PMDs using conditional logistic regression in the nested case-control study. Demographic factors (country of birth, educational level, region of residency, and cohabitation status) were adjusted for. We (2) calculated the hazard ratio (HR) and 95% CIs of PMDs subsequent to PND using stratified Cox regression in the matched cohort study. Smoking, BMI, parity, and history of psychiatric disorders were further controlled for, in addition to demographic factors. Pregnancies from full sisters of PND cases were identified for sibling comparison, which contrasts the risk within each set of full sisters discordant on PND. In the nested case-control study, we identified 2,488 PMDs (2.9%) before pregnancy among women with PND and 5,199 (0.6%) among controls. PMDs were associated with a higher risk of subsequent PND (OR 4.76, 95% CI [4.52,5.01]; p < 0.001). In the matched cohort with a mean follow-up of 7.40 years, we identified 4,227 newly diagnosed PMDs among women with PND (incidence rate (IR) 7.6/1,000 person-years) and 21,326 among controls (IR 3.8). Compared to their matched controls, women with PND were at higher risk of subsequent PMDs (HR 1.81, 95% CI [1.74,1.88]; p < 0.001). The bidirectional association was noted for both prenatal and postnatal depression and was stronger among women without history of psychiatric disorders ( p for interaction < 0.001). Sibling comparison showed somewhat attenuated, yet statistically significant, bidirectional associations. The main limitation of this study was that our findings, based on clinical diagnoses recorded in registers, may not generalize well to women with mild PMDs or PND.

Conclusions

In this study, we observed a bidirectional association between PMDs and PND. These findings suggest that a history of PMDs can inform PND susceptibility and vice versa and lend support to the shared etiology between both disorders.

Author summary

Why was this study done.

• Perinatal depression (PND) and premenstrual disorders (PMDs) share symptomology (e.g., feeling depressed), and the timing of symptom onset of both conditions coincides with natural hormonal fluctuations.
• Prospective data are lacking to study the potential bidirectional association between these conditions, which can guide clinical management.

What did the researchers do and find?

• We conducted a nested case-control study and transitioned that design into a matched cohort study with onward follow-up to simulate a prospective study design.
• Among approximately 1.8 million singleton pregnancies in Sweden during 2001 to 2018, we identified 84,949 women with PND and 849,482 unaffected women, individually matched on age and calendar year. Pregnancies from full sisters of women with PND were also identified for sibling comparison.
• Among women with PND, 2.9% had PMDs before pregnancy, in contrast to 0.6% among matched unaffected women. PMDs were associated with a nearly 5 times higher risk of subsequent PND. In the matched cohort with a mean follow-up of 6.90 years, women with PND had almost 2 times higher risk of subsequent PMDs, compared to matched unaffected women.
• The bidirectional association between PMDs and PND was noted for both prenatal and postnatal depression, regardless of history of psychiatric disorders, and also in sibling comparison.

What do these findings mean?

• These findings suggest that a history of PMDs can inform PND susceptibility and vice versa.
• The main limitation of this study was that our findings, based on clinical diagnoses or prescribed medications, may not generalize well to women with mild PMDs or PND.

Citation: Yang Q, Bränn E, Bertone- Johnson ER, Sjölander A, Fang F, Oberg AS, et al. (2024) The bidirectional association between premenstrual disorders and perinatal depression: A nationwide register-based study from Sweden. PLoS Med 21(3): e1004363. https://doi.org/10.1371/journal.pmed.1004363

Received: May 22, 2023; Accepted: February 19, 2024; Published: March 28, 2024

Copyright: © 2024 Yang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data are from the Swedish national healthcare registers. Data cannot be put into a public data repository according to Swedish law but are available by applying through Statistics Sweden or the Swedish National Board of Health and Welfare. Detailed information on data application can be found in the following links: https://www.scb.se/vara-tjanster/bestalla-mikrodata/ and https://bestalladata.socialstyrelsen.se/ .

Funding: The work was supported by the Chinese Scholarship Council (No. 201700260289 to QY), the Swedish Research Council for Health, Working Life and Welfare (FORTE) (No. 2020-00971 and 2023-00399 to DL), the Swedish Research Council (Vetenskapsrådet) (No. 2020-01003 to DL), Karolinska Institutet Strategic Research Area in Epidemiology and Biostatistics (grant to DL), Karolinska Institutet SFOepi Junior Scholar Grant (to DL) and the Icelandic Research Fund (No. 218274-051 to UAV). The funders had no role in study design, data collection and analysis, preparation of the manuscript or decision to publish.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: ACOG, American College of Obstetricians and Gynecologists; CI, confidence interval; HR, hazard ratio; IR, incidence rate; MBR, Medical Birth Register; MGR, Multi-Generation Registers; OR, odds ratio; PMD, premenstrual disorder; PMDD, premenstrual dysphoric disorder; PMS, premenstrual syndrome; PND, perinatal depression

Introduction

Premenopausal women experience natural hormonal fluctuations associated with various life events, such as puberty, menstrual cycle, pregnancy, and menopause. Some women are more likely to develop or manifest mood symptoms during these events. For instance, perinatal depression (PND) is characterized by depressive symptoms occurring during pregnancy and up to 12 months after delivery and affects 11% of mothers globally [ 1 ]. PND has been positively associated with maternal suicidal behavior and has a negative influence on mother–infant bonding [ 2 ]. Similarly, premenstrual disorders (PMDs) are characterized by somatic and/or psychological symptoms that recur in luteal phase. PMDs cause significant functional impairment [ 3 – 5 ]. PMDs affect 20% to 30% of women of reproductive age [ 4 ], and about 5% to 8% of women suffer from severe symptomology [ 3 ]. PMDs are associated with increased risks of suicidal behavior and accidents [ 6 ].

PND and PMDs share symptomology (e.g., feeling depressed) and the timing of symptom onset of both conditions coincides with natural hormonal fluctuations [ 7 , 8 ]. Therefore, it has been postulated that these disorders may have common etiology and shared risk factors [ 9 ]. This hypothesis is supported by 2 recent systematic reviews showing that women with PND were more likely to have a history of PMDs [ 10 , 11 ]. However, existing studies relied on retrospectively collected on data premenstrual symptoms during or after pregnancy, which might be prone to recall bias and thereby biased results [ 12 , 13 ]. Moreover, the community- or clinic-based sampling in previous studies may have introduced significant selection bias [ 14 ]. Premenstrual symptoms can worsen after pregnancy due to an escalated abnormal response to hormonal changes in relation to pregnancy [ 15 ]. It is thus plausible that women with PND are at risk for subsequent PMDs. However, few studies with a relatively small sample size have examined this hypothesis by comparing proportions without adjustment for confounders and generated inconsistent results [ 16 – 18 ].

Taken together, without prospective evidence, it remains unclear whether women with PMDs have an increased risk of developing PND when becoming pregnant or after giving birth and vice versa. Using the Swedish nationwide registers with prospectively collected data, we aimed to investigate the bidirectional association between PMDs and PND. To study the bidirectional association in the same population effectively, we conducted a nested case-control study, a design inherently equivalent to a cohort study [ 19 ]. To examine the risk of PND following PMDs in a manner that simulates a prospective approach, we then transitioned this design into a matched cohort study to assess the risk of PMDs after PND. We further employed sibling comparisons to account for shared genetic and familial environmental risk factors for both disorders.

Data sources

Based on the Medical Birth Register (MBR), we identified 1,803,309 singleton pregnancies from 1,041,419 women during 2001 to 2018. The MBR covers virtually all births in Sweden since 1973, with rich information prospectively collected from prenatal, delivery, and neonatal care [ 20 , 21 ]. Multiple births ( n = 51,824), pregnancies after PND diagnosis ( n = 34,790), pregnancies from women who emigrated before 2001 ( n = 952), or pregnancies before age 15 or after age 52 ( n = 383) were excluded. The Patient Register, Prescribed Drug Register, Migration Register, Causes of Death Register, and Multi-Generation Register (MGR) were cross-linked using the unique personal identification number. The Patient Register collects information on all inpatient admissions for psychiatric care since 1973 and for somatic diseases since 1987 and >80% outpatient visits since 2001 [ 22 ]. The Prescribed Drug Register contains information on medications redeemed from all pharmacies in Sweden since July 2005 [ 23 ]. MGR contains information on familial links for individuals born from 1932 onward [ 24 ].

Ascertainment of PND

In line with previous studies [ 25 ], we identified PND from the date obtained by subtracting gestational age from the delivery date till 1 year postpartum, using the Swedish version of International Statistical Classification of Diseases and Related Health Problems (ICD)-10 codes (F32, F33, and F53.0) recorded in the MBR and Patient Register. According to the Swedish National Board of Health and Welfare, F32 and F33 are ICD-10 codes used to identify depression in Swedish healthcare registers according to the Swedish National Board of Health and Welfare [ 26 ] and have been reported to have high validity in the Swedish population (κ of 0·32; 88% full agreement with gold standard) [ 27 ]. F53.0 identifies perinatal depression not captured elsewhere [ 26 ]. Gestational age was, whenever possible, estimated according to ultrasound, which has been offered to all pregnant women in Sweden since 1990 and is performed for 95% of all pregnancies [ 28 ]. Nearly half of mental health problems are managed in primary care in Sweden [ 29 ]. Therefore, any prescription of antidepressants (ATC code N06A) was also considered as a proxy for PND. Antidepressants are commonly prescribed for PMDs as first-line treatment [ 30 ]. Prescriptions of antidepressants with an indication for PMDs, as described elsewhere [ 6 ], were not considered. The date of PND diagnosis was defined as the date of receiving a clinical diagnosis or filling a prescription of antidepressants, whichever came first. Since the MBR does not record the date of diagnosis and/or drug use, the median date of pregnancy was assigned as diagnosis date for those identified through MBR. Perinatal depression was then subcategorized into prenatal and postnatal depression using delivery date as cutoff point.

Ascertainment of PMDs

Clinical diagnoses of PMDs were retrieved from the Patient Register (ICD-10 code N943). PMDs include premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). In practice, PMS is often diagnosed based on criteria similar to the American College of Obstetricians and Gynecologists (ACOG) criteria [ 31 ], and PMDD is diagnosed in accordance with diagnostic criteria described in DSM-5 [ 32 ]. According to the Swedish guidelines, prospective daily symptom ratings for at least 2 consecutive menstrual cycles are required [ 33 ]. To capture diagnoses made in primary care, we identified all prescriptions of antidepressants (ATC codes N06AA, N06AB, and N06AX) and contraceptives (G02B and G03A) with a specified clinical indication of PMDs from the Prescribed Drug Register. Indications of PMDs were specified by the prescribers as free-text and identified with key word recognition, as described previously [ 6 ].

Study design

We identified 84,949 incident cases of PND, including 47,424 cases of prenatal depression and 37,525 cases of postnatal depression. Using incidence density sampling, 10 controls that were free from PND at the time when the matched case was diagnosed were randomly selected for each case. Controls were matched on gestational age for prenatal depression cases and matched on postnatal day for postnatal depression cases, together with maternal age ( n = 849,482). To effectively examine the bidirectional association between PMDs and PND within the same study population, we conducted a nested case-control study, a design inherently equivalent to a cohort study [ 19 ], identifying all pregnancies, corresponding PNDs and previous history of any indications for PMDs to examine the risk of PND following PMDs in a manner that simulates a prospective approach. We then transitioned this design into a matched cohort with onward follow-up of index PNDs and control pregnancies, enabling us to efficiently assess the risk of PMDs after PND within the same study population. The matching date was used as the index date. Women who had PMDs before their index date were excluded ( n = 7,687) and, as they were not at risk for incident PMD diagnosis. All women were then followed from 6 months after delivery (by when over 90% of Swedish women had stopped complete breastfeeding) [ 34 ] or the index date, whichever came later, until age 52, emigration, PMD diagnosis, or end of follow-up, whichever came first. During the follow-up, we observed 500 deaths in PND group and 1,559 deaths in matched controls.

The study design is illustrated in S1 Fig . The study was approved by the Regional Ethics Review Board in Stockholm (No. 2018-1515/31). Written informed consent is waived for register-based studies by Swedish law. This study is reported as per the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline ( S1 Checklist ).

Information on the following covariates were retrieved: demographics (maternal age, country of birth, cohabitation status, region of residence, and educational level), smoking 3 months before the pregnancy, BMI in early pregnancy, parity, history of psychiatric disorders before pregnancy, and pregnancy complications and adverse outcomes including hypertensive and diabetic diseases, preterm birth (gestational week <37 weeks), stillbirth, low birth weight (birth weight<2,500 grams), congenital malformations of the offspring, and neonatal death of the offspring (death within 28 days of birth). Data origin and rational of the choice of covariates are described in S1 Methods . ICD codes are summarized in S1 Table , and categorization for covariates are presented in Table 1 . Missing values in covariates were coded as unknown for adjustment.

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pmed.1004363.t001

Statistical analysis

We firstly compared the distributions of characteristics between PND cases and their matched controls.

PMDs and subsequent risk of PND.

In the nested case-control study, we calculated the percentage of PMDs before pregnancy for PND cases and controls separately and estimated odds ratios (ORs) and 95% confidence intervals (CIs) using conditional logistic regression. The nested case–control analysis, by design, is equivalent to the analysis using full cohort (i.e., assessing the incidence of PND subsequent to PMDs). Using incidence density sampling for individual matching, the estimate OR can be interpreted as hazard ratio (HR) of PND, comparing women with and without PMDs before pregnancy [ 19 ]. This analysis was repeated separately for prenatal and postnatal depression, and PND diagnosed in different time windows [first trimester (within 13 gestational weeks) or second to third trimester for prenatal depression, and 0 to 3, 4 to 6, or 7 to 12 months after delivery for postnatal depression].

Both PMDs and PND are correlated with depression and other psychiatric disorders [ 35 , 36 ]. An interaction term between history of psychiatric disorders and PND was added to explore potential effect modification. Because parity is associated with many pregnancy complications and outcomes [ 37 ], we performed separate analyses for primi- and multiparous women. To explore effect modification by maternal age and calendar year, we also conducted stratified analysis by maternal age (categorized into 15 to 30 and 31 to 52) and calendar year at pregnancy.

PND and subsequent risk of PMDs.

In the matched cohort study, we calculated the incidence rate (IR) of PMDs among PND cases and matched controls and HRs and 95% CIs of PMDs using Cox regression (attained age as the underlying time scale and matching sets as strata). The proportional hazard assumption was deemed reasonable by inspecting the Schoenfeld residuals. Consistent with the nested case-control analyses, we performed analyses by PND subtype (pre- and postnatal depression and PND diagnosed in different time windows) and other stratification analyses.

Adjustment.

Model 1 accounted for the matching variables and Model 2 accounted for other demographic factors (country of birth, educational level, region of residency, and cohabitation status). In Model 3, smoking, BMI, parity, and history of psychiatric disorders were further controlled for. We considered Model 3 as the primary for the matched cohort study and Model 2 for the nested case-control study since these covariates were instead possible mediators in this scenario.

Sibling analysis.

PMDs and PND may have shared risk factors, such as poor support from family members and genetic factors [ 10 , 11 ], which would confound the studied associations. Sibling comparison contrasts the risk within each set of full sisters discordant on PND and inherently controls for unmeasured confounders shared between full sisters [ 38 ]. Briefly, all pregnancies from PND cases and their full sisters were identified through MBR linked to MGR. In total, 56,941 pregnancies from 40,665 full sisters (18,869 PND cases) were included. We examined the bidirectional association using conditional logistic regression and stratified Cox regression.

Additional analyses.

We limited the analysis to (1) PMDs with at least 2 specialists’ PMD diagnoses ≥28 days apart to test the validity of PMD diagnosis; (2) PND identified through clinical diagnosis alone to reduce misclassification by using dispensation of antidepressants; and (3) women without severe pregnancy complications or adverse delivery outcomes since they might confound or mediate the studied associations through chronic stress associated with such events [ 39 ]. Due to lack of individual-level data on return of postpartum menstruation, we performed a sensitivity analysis of cohort follow-up starting from 2, 3, or 12 months postpartum.

Data were prepared in SAS statistical software version 9.4 (SAS Institute, Cary, NC) and analyzed in Stata 15.1 (STATA, College Station, TX). The statistical significance was set at the nominal two-sided 5% level.

Characteristics

The median age was 30.71 at PND diagnosis. Compared to the controls, women with PND were less educated, were more likely to be born in Sweden, live alone and in South Sweden, had a higher BMI, were more likely to smoke, and have been diagnosed with psychiatric disorder before the pregnancy (all p -values < 0.001; Table 1 ). They were also more likely to be primiparous, deliver through cesarean section, and experience pregnancy complications and adverse pregnancy and birth outcomes (all p -values < 0.001; Table 1 ).

PMDs and subsequent risk of PND

We identified 7,687 women with PMDs before pregnancy (2,488 among women with PND) in the nested case-control study. PMDs were associated with a higher risk of subsequent PND (OR 4.98, 95% CI [4.74,5.23]; p < 0.001). Additional adjustment of demographic factors including country of birth, educational level, region of residence, and cohabitation status slightly attenuated the observed association (OR 4.76, 95% CI [4.52,5.01]; p < 0.001) ( Table 2 ). The association was observed for both prenatal (OR 4.58, 95% CI [4.28,4.90]; p < 0.001) and postnatal (OR 5.03, 95% CI [4.65,5.45]; p < 0.001) depression. Moreover, the association remained robust across different pre-/postnatal phases; the OR was lower for prenatal depression diagnosed during first trimester than for those diagnosed later during pregnancy and lower for postnatal depression within 6 months after delivery than those diagnosed during 7 to 12 months ( Table 2 ). Attenuated but statistically significant results were observed after adjusting for potential mediators including history of psychiatric disorders ( S2 Table ).

https://doi.org/10.1371/journal.pmed.1004363.t002

In the stratified analysis, an association between PMDs and subsequent PND was observed regardless of previous history of psychiatric disorders and was stronger among women without such history ( p for interaction < 0.001) ( Table 3 ). The association was stronger among multiparous than primiparous women and was comparable across maternal age and calendar year groups ( S3 Table ).

https://doi.org/10.1371/journal.pmed.1004363.t003

PND and subsequent risk of PMDs

During a mean follow-up of 6.90 years (standardized deviation 4.31, range 0.003 to 17.50) from 6 months postpartum onwards, we identified 25,553 newly diagnosed cases of PMDs (4,227 among women with PND) in the matched cohort study. Compared to their matched controls, women with PND were at higher risk of PMDs (HR 2.00, 95% CI [1.93,2.07]; p < 0.001). Adjustment for pregnancy characteristics, history of psychiatric disorders, together with demographic factors slightly attenuated the association (HR 1.81, 95% CI [1.74,1.88]; p < 0.001) ( Table 4 ). Estimated HRs were 1.67, 95% CI [1.58,1.76]; p < 0.001 for prenatal and 1.98, 95% CI [1.87,2.09]; p < 0.001 for postnatal depression. Similar associations were found across time windows during pregnancy and after delivery ( Table 4 ).

https://doi.org/10.1371/journal.pmed.1004363.t004

The association between PND and subsequent PMDs was stronger among women without a history of psychiatric disorder in the stratified analysis ( p for interaction < 0.001) ( Table 5 ). The association did not differ by parity and calendar year and was somewhat greater among women aged 31 to 52 years at pregnancy ( S4 Table ).

https://doi.org/10.1371/journal.pmed.1004363.t005

Additional analyses

Largely comparable bidirectional associations between PMDs and PND were observed in the sibling comparison, although results were somewhat attenuated compared to the population comparison ( Table 6 ).

https://doi.org/10.1371/journal.pmed.1004363.t006

In both study designs, robust bidirectional associations were observed when restricting to (1) women without pregnancy complications or adverse outcomes; (2) PMDs with 2 specialists’ diagnoses ≥28 days apart; and (3) PND ascertained through clinical diagnosis ( S5 Table ). Moreover, similar results were observed with different start of follow-up in the cohort study ( S6 Table ).

In the present study based on data from Swedish national registers, we found a bidirectional link between premenstrual disorders and perinatal depression, which was pronounced for prenatal and postnatal depression and slightly stronger for postnatal depression. The bidirectional association was verified among women without a history of psychiatric disorders. These findings were corroborated, despite the attenuation, in the sibling comparison, which controls for familial environmental and genetic factors.

Previous studies have used data on history of PMDs retrospectively collected during or after pregnancy, which might be vulnerable to recall bias and systematic error [ 12 , 13 ]. Taking advantage of prospectively collected data in Swedish healthcare registers, the study is the first, to our knowledge, to demonstrate a positive association between PMDs and subsequent risk of PND. Moreover, previous studies exclusively focused on postnatal depression, mostly ascertained within 8 weeks postpartum [ 10 , 11 ]. With retrospectively collected data, one systematic review and one meta-analysis reported that women with postnatal depression were more likely to endorse a history of PMDs [ 10 , 11 ], which is in line with our results. The meta-analysis reported an OR of 2.20, 95% CI [1.81,2.68] for PMDs among women with postnatal depression (mostly assessed within 6 months after delivery) [ 10 ]. Correspondingly, our data show that women with PMDs have more than 3 times higher risk of PND within 6 months postpartum.

To our knowledge, no study has examined the association between prenatal depression and PMDs. Our findings on prenatal depression therefore extend knowledge to another subtype of PND that occurs during pregnancy. Although the etiology for prenatal depression is complex [ 40 ], our finding may suggest a subgroup of prenatal depression may be related to hormone changes as well. However, future studies are needed to confirm our results and to understand the biologic link between PMDs and prenatal depression. Interestingly, we found a stronger association between PMDs and PND among multiparous than primiparous women. It is known that primiparous women have a higher risk of PND [ 41 ] while parity is positively associated with PMDs [ 42 ]. It is plausible that premenstrual symptoms can worsen after pregnancy likely due to an escalated abnormal response to hormonal changes in relation to pregnancy [ 15 ]. However, it is unclear whether multiple pregnancies would further deteriorate the pathological response to hormone fluctuations. Future studies are needed to better understand the potential mechanisms.

Our work illustrates a higher risk of PMDs among women who experienced PND. Although many women with PMDs have symptom onset in adolescence [ 43 ], symptom worsening has been reported with increasing age [ 44 ] and parity [ 15 ]. It is possible that women with milder premenstrual symptoms experienced worse symptoms after pregnancy and are therefore first diagnosed with PMD after pregnancy. The delayed diagnosis of PMD could be one reason for this finding [ 45 ]. Interestingly, we noted a stronger association between PMDs and subsequent PND than the association in the other direction. This might be because many PMDs have an early onset [ 43 ], likely before the average age at first childbirth, whereas we targeted the late-onset PMDs in the cohort study. It is also plausible that women with PND are more likely to take antidepressants, which may mitigate premenstrual symptoms. On the other direction, although women with PMDs may use antidepressants as well, women are more likely to discontinue psychotic medications during pregnancy and even after due to breastfeeding [ 46 , 47 ]. However, future studies are warranted to disentangle the role of treatment in the differential associations observed for both directions.

There are several explanations to the bidirectional association between PMDs and PND. First, both PMDs and PND have shared liability with psychiatric disorders [ 35 , 36 ], which may explain the findings. PMDs could also lead to the development of psychiatric comorbidities [ 48 ], which increase the risk of PND. In this scenario, psychiatric disorders are mediators of the studied associations. Indeed, additional adjustment of psychiatric disorders attenuated the associations. However, the bidirectional associations (relative risks) remained robust and even stronger among women without a history of psychiatric disorders, suggesting our findings cannot be entirely explained by psychiatric disorders. On the other hand, although the absolute risk (e.g., probability or incidence rate) of PMDs is higher among women with a psychiatric history, a diagnosis of PND does not translate into an increased risk of PMDs to the same extent as it does for those without a psychiatric history. This is likely because the already heightened risk of PMDs among women with a psychiatric history, particularly among those with a history of depression. However, PMDs or PND have a relatively weaker correlation with other psychiatric disorders compared to depression [ 35 , 36 ]. Among women with a history of other psychiatric disorders, PMDs appeared to confer a higher risk of PND ( Table 3 ) and vice versa ( Table 5 ). Second, PMDs and PND may share other risk factors such as obesity and smoking [ 4 , 49 , 50 ]. However, the bidirectional association persisted after adjustment of BMI and smoking. Childhood adversities could be another shared risk factor [ 51 , 52 ]. However, sibling comparison should to some extent have addressed that, at least with respect to adversities shared between full sisters. Third, PMDs and PND may share genetic susceptibility. The twin heritability was estimated to be around 54% for PND [ 53 ] and 44% to 95% for PMDs [ 54 – 56 ]. Indeed, the attenuation of the associations in sibling comparison lends support to the shared genetic factors and/or familial environmental factors between both disorders. But the associations remained despite the attenuation in sibling comparison. Last, PMDs and PND may share common etiology. The symptom onset of both disorders is linked to hormonal fluctuations, particularly of estrogen and progesterone, which have receptors in the brain, and have been linked to mood alterations [ 57 , 58 ]. PND occurs during a period that is marked with rapid increase of steroid hormones during pregnancy and a rapid decline after delivery [ 7 ]. Similarly, the onset of PMD symptoms typically follows the rapid withdraw of hormones in the late luteal phase [ 8 ]. It is plausible that an abnormal response to natural hormone fluctuations predisposes women to both PMDs and PND. Future research is, however, needed to reveal the potentially shared underlying etiology of both conditions.

The strength of the study lies in the large sample size with long and complete follow-up, the prospectively and independently collected data on PMDs and PND, and covariates that could confound the studied association. The nested-case control study in combination with the transition into a matched cohort study with onward follow-up allowed us to study the association between PMDs and PND in a bidirectional fashion with efficiency, which is equivalent to two independent cohort studies within the same study population. Moreover, the sibling comparisons allowed us to address the influence of familial factors. However, the study has several limitations. First, the clinical diagnosis of PMDs in the Swedish Patient Register has not been validated. Although prospective daily symptom ratings for at least two consecutive menstrual cycles are required for diagnosing PMDs in Sweden according to the guidelines [ 33 ], we cannot confirm that the clinical decision to assign a diagnosis or medical treatment to every single ascertained PMD in the registers is based on prospective daily ratings. However, clinical guidelines are often well followed owing to the state-funded nature of the public healthcare system in Sweden. Moreover, the Swedish Patient Register has fairly high validity in general [ 59 ], with the overall positive predicted value for most diagnoses ranging from 85% to 95% [ 60 ]. For a range of psychiatric disorders [ 61 – 64 ] and gynecologic diseases [ 22 , 65 ], the diagnosis has been reported to have high validity. Lastly, sensitivity analysis restricting to PMDs with at least two specialist-made diagnoses at least 28 days apart yielded similar results. In addition, the diagnostic criteria for PMDs may have changed over time. However, stratification analysis by calendar year showed similar results, suggesting that our results are robust given the changes of labeling and diagnostic criteria for PMDs over time. Second, using prescription of antidepressants to identify PND cases might result in misclassifications because antidepressants are also prescribed for other psychiatric disorders. However, sensitivity analysis restricted to clinically diagnosed PND cases showed comparable results. Moreover, reverse causation may to some extent contribute to the observed associations, although we tried to minimize the risk for such bias through the study design that simulates a prospective approach. For instance, some individuals might already have PMDs before pregnancy but received the diagnosis when seeking healthcare for PND. However, similar results have been found when starting the follow-up 1 year after delivery, when such prevalent PMDs would presumably have been captured sooner after the delivery during the postpartum checkups. Third, we did not have data on the exact date of menstruation return for postpartum women, which could be individually different and affected by multiple factors including breastfeeding practices and mode of delivery. Nevertheless, sensitivity analysis with different starting points of the follow-up yielded similar results. Lastly, relying on the Patient Register, we would have missed cases with less severe symptomology and did not seek healthcare service. Moreover, with the ICD code we used to identify PND, we might have missed a small number of mood disturbances or affective disorders that are not sufficiently severe or long-lasting to be classified as depressive episodes. Our findings thus may not generalize well to women with mild PMDs or PND symptomology.

In conclusion, our findings shed light on the bidirectional association between PMDs and PND, supporting a shared underlying etiology. Preconception and maternity care providers should be aware of the risk of developing PND among women with a history of PMDs. Moreover, healthcare providers may inform women with PND about the potential risk of PMDs when menstruation returns after childbirth. The bidirectional relationship is, to a limited extent, explained by psychiatric comorbidities and familial confounding.

Supporting information

S1 checklist. strobe statement—checklist of items that should be included in reports of observational studies..

https://doi.org/10.1371/journal.pmed.1004363.s001

S1 Methods. Data origin and rational of the choice of covariates.

https://doi.org/10.1371/journal.pmed.1004363.s002

S1 Fig. Flow chart.

https://doi.org/10.1371/journal.pmed.1004363.s003

S1 Table. International Classification of Diseases codes used to define the studied medical conditions.

https://doi.org/10.1371/journal.pmed.1004363.s004

S2 Table. Association of premenstrual disorders (PMDs) with subsequent risk of perinatal depression (PND) adjusted for mediators: A nested case-control study.

https://doi.org/10.1371/journal.pmed.1004363.s005

S3 Table. Stratified association of premenstrual disorders (PMDs) with subsequent perinatal depression (PND): A nested case control study.

https://doi.org/10.1371/journal.pmed.1004363.s006

S4 Table. Stratified association of perinatal depression (PND) with subsequent premenstrual disorders (PMDs): A matched cohort study.

https://doi.org/10.1371/journal.pmed.1004363.s007

S5 Table. Bidirectional link between perinatal depression (PND) with premenstrual disorders (PMDs): Sensitivity analysis.

https://doi.org/10.1371/journal.pmed.1004363.s008

S6 Table. Association of perinatal depression (PND) with subsequent premenstrual disorders (PMDs): A matched cohort study with different start of follow-up.

https://doi.org/10.1371/journal.pmed.1004363.s009

• View Article
• PubMed/NCBI
• Google Scholar
• 13. ACOG. Premenstual Syndrome (PMS). May, 2015; Available from: https://www.acog.org/womens-health/faqs/premenstrual-syndrome .
• 21. The Swedish Medical Birth Register—A Summary of Content and Quality. 2019-04-15, Socialstyrelsen: Sweden.
• 26. The Swedish National Board of Health and Welfare. Klassifikationer. 2023 2023-01-01 [cited 2024 Jan 25]; Available from: https://klassifikationer.socialstyrelsen.se/ .
• 33. Region Stockholms läkemedelskommittés expertgrupp för kvinnosjukdomar och förlossning. Riktlinjer vid premenstruell dysforisk störning, PMDS. 2023-03-13 [cited 2024 Jan 25]; Available from: https://janusinfo.se/behandling/expertgruppsutlatanden/kvinnosjukdomarochforlossning/kvinnosjukdomarochforlossning/riktlinjervidpremenstruelldysforiskstorningpmds.5.6081a39c160e9b387319f3.html .
• 34. Socialstyrelsen. Statistics on breastfeeding 2021-05-25 [cited 2022 Mar 28]; Available from: https://www.socialstyrelsen.se/statistik-och-data/statistik/alla-statistikamnen/amning/ .
• 59. Forsberg L, R.H., Jacobsson A, Nyqvist K, Heurgren M, Kvalitet och innehåll i patientregistret. Utskrivningar från slutenvården 1964–2007 och besök i specialiserad öppenvård (exklusive primärvårdsbesök) 1997–2007. (Quality and content of the Patient Register)(2009-125-15), in Kvalitet och innehåll i patientregistret. Utskrivningar från slutenvården 1964–2007 och besök i specialiserad öppenvård (exklusive primärvårdsbesök) 1997–2007. (Quality and content of the Patient Register)(2009-125-15). 2009: Stockholm.

Hon’ble Chancellor Vice Chancellor Registrar Principal Vice Principal Medical Superintendent

Anaesthesiology Anatomy Biochemistry Cardiac Anaesthesia Cardiology Cardio vascular & Thoracic Surgery Community Medicine Dermatology (Skin & VD) Emergency Medicine Endocrinology ENT, Head & Neck Surgery Forensic Medicine Gastroenterology

General Medicine General Surgery Interventional Radiology Medical Oncology Microbiology Nephrology Neonatology Neurology Neurosurgery Nuclear Medicine Obstetrics & Gynecology Ophthalmology Orthopedics Pathology

Public Health Research Unit Medical Education MCI Nodal Center Hospital Administration

Pediatrics Pediatric Neurology Pediatric Surgery Pharmacology Physical Medicine & Rehabilitation Physiology Plastic & Reconstructive surgery Psychiatry Radiation Oncology Radiology/Radio-diagnosis Respiratory/Pulmonary Medicine Surgical Oncology Urology

Under Graduate

Post graduate.

Post Doctoral Diploma Courses Public Health Ph.D Hospital Administration Fellowship Courses Allied Courses

Feedback Analysis 2015-20 Feedback Analysis 2021

Syllabus of Courses offered

Under Graduate Post Graduate Post Doctoral Fellowship Courses Ph.D Allied Courses

• KLE Advanced Simulation Centre & Clinical Skills Lab
• Cadaveric Skill Lab
• NIRF Prescribed Format
• JNMC NIRF 2018
• JNMC NIRF 2019
• JNMC NIRF 2020
• JNMC NIRF 2021
• JNMC NIRF 2022
• JNMC NIRF 2023
• JNMC NIRF 2024
• KLE Dr. PBK Hospital & MRC
• KLE Dr.PBK Hospital
• JNMC Women’s & Children’s Health Research Unit
• KLE Society
• Sports Complex
• Convention Center
• Musical Garden
• Shivalaya Temple
• Ganesh Temple
• Attendance Dashboard
• Scientific Society
• Student Association
• Kannada Balaga
• Institutional Ethics Committee
• Internal Complaint Committee
• Anti-Ragging
• Para Medical Course
• Capability Enhancement
• Faculty Login
• Student/Parent Login
• Dissertations
• M.B.B.S Phase III – Part-II

ONGOING DISSERTATION

COMPLETED DISSERTATION

Request a Quote

• Hon’ble Chancellor
• Vice Chancellor
• Vice Principal
• Medical Superintendent
• Biochemistry
• Forensic Medicine
• Microbiology
• Pharmacology
• Community Medicine
• Ophthalmology
• Obst & Gynecology
• Orthopaedics
• Skin & VD
• Pulmnonary Medicine
• Anaesthesiology
• Post Doctoral
• Endocrinology
• Department Public Health
• Research Unit
• Medical Education
• MCI Nodal Center
• Diploma Courses
• Department of Public Health
• Hospital Administration
• Govt-Approval
• KLE Dr. PBK Hospital & MRC
• KLE Dr.PBK Charitable Hospital
• PHC & UHC

Anthropology

Anthropology doctoral student ebenezer adeyemi was awarded a t. anne cleary international dissertation research fellowship from the ui graduate college.

Anthropology doctoral student Ebenezer Adeyemi was awarded a T. Anne Cleary International Dissertation Research Fellowship from the UI Graduate College. Ebenezer’s research interests center around medical anthropology, infrastructure, the intersection of urban landscape and public health, African studies, and survival strategies in marginalized urban communities. For his ongoing doctoral research, Ebenezer is exploring strategies that residents of Makoko, a large informal settlement in Lagos State, Nigeria, use to access healthcare to treat malaria, the most prominent health issue in their community.   

NOTICE: The University of Iowa Center for Advancement is an operational name for the State University of Iowa Foundation, an independent, Iowa nonprofit corporation organized as a 501(c)(3) tax-exempt, publicly supported charitable entity working to advance the University of Iowa. Please review its full disclosure statement.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• BMC Med Res Methodol

Qualitative research methods in medical dissertations: an observational methodological study on prevalence and reporting quality of dissertation abstracts in a German university

Charlotte ullrich.

Department of General Practice and Health Services Research, University of Heidelberg Hospital, INF 130.3, 69120 Heidelberg, Germany

Anna Stürmlinger

Michel wensing, associated data.

The data of the repository databank is semi-public and can be accessed from the corresponding author upon reasonable request. A data extraction table is available in App. 2.Competing interests and funding: We have no conflicts of interest to disclose and no funding to report.

Qualitative methods offer a unique contribution to health research. Academic dissertations in the medical field provide an opportunity to explore research practice. Our aim was to assess the use of qualitative methods in dissertations in the medical field.

By means of a methodological observational study, an analysis of all academic medical dissertations’ abstracts between 1998 and 2018 in a repository databank of a large medical university faculty in Germany was performed. This included MD dissertations (Dr. med. (dent.)) and medical science dissertations (Dr. sc. hum.). All abstracts including “qualitativ*” were screened for studies using qualitative research methods. Data were extracted from abstracts using a category grid considering a) general characteristics (year, language, degree type), b) discipline, c) study design (mixed methods/qualitative only, data conduction, data analysis), d) sample (size and participants) and e) technologies used (data analysis software and recording technology). Thereby reporting quality was assessed.

In total, 103 abstracts of medical dissertations between 1998 and 2018 (1.4% of N  = 7619) were included, 60 of MD dissertations and 43 of medical sciences dissertations. Half of the abstracts ( n  = 51) referred to dissertations submitted since 2014. Most abstracts related to public health/hygiene ( n  = 27) and general practice ( n  = 26), followed by medical psychology ( n  = 19). About half of the studies ( n  = 47) used qualitative research methods exclusively, the other half ( n  = 56) used mixed methods. For data collection, primarily individual interviews were used ( n  = 80), followed by group interviews ( n  = 33) and direct observation ( n  = 11). Patients ( n  = 36), physicians ( n  = 36) and healthcare professionals ( n  = 17) were the most frequent research participants. Incomplete reporting of participants and data analysis was common ( n  = 67). Nearly half of the abstracts ( n  = 46) lacked information on how data was analysed, most of the remaining ( n  = 43) used some form of content analysis. In summary, 36 abstracts provided all crucial data (participants, sample size,; data collection and analysis method).

A small number of academic dissertations used qualitative research methods. About a third of these reported all key aspects of the methods used in the abstracts. Further research on the quality of choice and reporting of methods for qualitative research in dissertations is recommended.

Qualitative research methods offer a unique contribution to health research, particular for exploration of the experiences of patients, healthcare professionals and others [ 1 – 5 ]. While (general) epidemiology primarily addresses health and healthcare in populations and clinical research concentrates on medical interventions and health prognosis, qualitative research methods focus on different actors’ perspectives, experiences and behaviours in health-related contexts. Qualitative research entails a broad spectrum of methods of data conduction and data analysis: individual interviews illuminate individual perceptions [ 6 ], group interviews deliver insights into shared norms and opinions [ 7 ], direct observations facilitate understandings of behaviours in healthcare practice [ 8 – 10 ] and documents can offer insights into discourses and self-representations [ 11 ]. For data analysis, methods combining inductive and deductive steps are most suitable for exploratory research questions utilizing existing results, theories and concepts [ 12 ]. Given these prospects, little is known on the practice of applying qualitative research methods, especially concerning medicine.

In dissertations, a foundation for future scientific work is laid; therefore, guidance and rigour are of special importance [ 13 ]. Dissertations in medical departments provide a good opportunity to explore research practices of students and young academics. In Germany, about 60% of all graduating medical students complete an academic dissertation [ 14 ], which they usually finish parallel to medical school within a full-time equivalent of about a year [ 15 – 18 ]. As a by-product, medical doctoral students are increasingly among the authors of published research, holding first-authorship in about 25% [ 18 – 20 ].

In Germany, basic scientific training is a required part of the medical curriculum and recent policies put even more emphasis on the development of scientific competencies [ 15 , 21 , 22 ]. National regulations specify scientific competencies giving explicit recommendations for quantitative methods. Medical students have rarely received training in qualitative methods. However, health care professions and qualitative methods share a perspective directed to practice and interactions. Interviews and observations are already commonly used as clinical and diagnostic tools.

In addition to the doctoral degrees for medical and dental graduates (Doctor medicinae (dentariae), Dr. med. (dent.)), students with other disciplinary backgrounds (e.g. natural scientists, psychologists and social scientists) complete dissertations at medical faculties in Germany (often labelled Doctor scientiarum humanarum, Dr. sc. hum. or Doctor rerum medicarum, Dr. rer. medic.). Although regulations differ slightly, the degrees are usually situated within and regulated by the same institutional culture and context (e.g. faculty, department, supervision and aspired publications).

The aim of this study was to understand the current practice of applying qualitative research methods helping identify gaps in reporting and need for guidance. By means of a methodological study – a subtype of observational studies that evaluates the design, analysis of reporting of other research-related reports [ 23 ] – we investigated volume and variety of the use of qualitative research methods in dissertations at a German medical faculty. Hereby we wanted to inform methodological advances to health research and outline implications for medical education in scientific competencies training.

Search strategy

Dissertations in the medical field were retrospectively assessed: In a document analysis, all dissertation abstracts at one medical faculty were reviewed. This faculty was chosen as it is one of the oldest and largest medical faculties in Germany, with a strong research tradition and a high dissertation rate among graduating students. All abstracts from 01/01/1998 to 31/12/2018, which were publicly available in the repository databank of the university, were reviewed. This included MD dissertations (Dr. med. (dent.)) and medical science dissertations (Dr. sc. hum.) written in German or English. All types of studies using qualitative research methods, all types of human participants, all types of interventions and all types of measures were eligible. We focused on abstracts, because full text dissertations are not publicly available and are helpful to get an overview of a number of method-related issues. Although serving as a proxy, abstracts should provide a sufficient summary of the dissertation, including crucial information on study design, independently from the full text. In the databank, relevant documents had to be labelled a) “abstract of a medical dissertation” (referring to both degree types). To further identify dissertations using qualitative methods b) the search term “qualitativ*” was used as an inclusion criterium.

Selection and data extraction

All identified abstracts were pre-screened independently by two researchers (AS, LS) and then reviewed by the main research team (KK, AS, CU) excluding abstracts using “qualitativ*” only in respect to non-methods-related issues (e.g. quality of life). Data on a) general characteristics (year, language, degree type), b) discipline, c) study design (mixed methods/qualitative only, data conduction, data analysis), d) sample (size and participants) and e) technologies used (data analysis software and recording technology) (see App. 2) was then extracted independently by two team members (AS, LS) and crossed-checked (KK, CU). Data extraction was initially guided by two widely used reporting guidelines for qualitative health research articles [ 24 , 25 ] and adapted to reflect the abstract format: Abstracts provided comparable information on the set-up of study design and sample. Reporting of results was not assessed due to heterogeneity and briefness. Data extraction forms were piloted and adjusted to inductive findings. Disagreements were discussed, assessed and solved by consensus by the main research team (KK, AS, CU). Extracted data were analysed and reported as absolute and relative frequencies. As all abstracts were available, no further data was obtained from authors.

Search results

Out of a total of 7619 dissertation abstracts, 296 dissertations were initially identified. Of these, 173 abstracts were excluded from the study as “qualitativ*” in these abstracts did not refer to the research method. Additionally, 20 abstracts (12 medicine, 8 medical science) were not further included in the analysis due to an ambiguous and inconclusive use of the label “qualitative methods” and/or restricted comparability with the otherwise pre-dominant interview-based study designs: a) a qualitative research design was stated, but no further information on the approach was given ( n  = 7), b) no explicit distinction was made between qualitative research design and a clinical diagnostic approach ( n  = 4), c) the qualitative approach comprised of additional free text answers in written questionnaires only ( n  = 6), and d) only document analysis or observation was used ( n  = 3). In total, 103 abstracts (1.4% of 7619) were included in the analysis.

Low but increasing use

Since 1998, the number of dissertations applying qualitative methods has continually increased while the total number of dissertations remained stable (between n  = 314 in 2006 and n  = 410 in 1999 and 2008, M (1998–2018) = 362.8, SD = 26.1) (Fig.  1 ). Before 2005 there was yearly not more than one dissertation that used qualitative methods. Since then, the number has steadily raised to more than 10 dissertations per year, equivalent to an increase from 0.28% in 1998 to 3.42% in 2018 of all listed dissertation abstracts per year.

Number of all dissertations and dissertations using qualitative methods per year between 1998 and 2018

General characteristics

Abstracts nearly equally referred to dissertations leading to an MD degree (Dr. med. n  = 57, Dr. med. Dent. n  = 3) and medical science degree (Dr. sc. hum. n  = 43), respectively. The included dissertation abstracts were based in 12 different sub-specialties , most in general practice ( n  = 26), in public health and hygiene ( n  = 27) and medical psychology ( n  = 19); the Dr. med. (dent.) abstracts having a higher share in general practice ( n  = 21) and the Dr. sc. hum. abstracts in public health/hygiene ( n  = 16) (s. Table  1 ).

Usage of qualitative research design in dissertations at a medical faculty

Most abstracts followed at least roughly the common structure of background, methods, results and conclusion. The length of the abstracts varied between less than one and more than three pages, with most abstracts being one to two pages long; 77 abstracts were written in German and 26 in English.

Study design

About half of the studies used qualitative research methods exclusively ( n  = 47; 60% of Dr. med. (dent.) abstracts, 26% of Dr. sc. hum. abstracts), the other half mixed methods ( n  = 56; 40% of Dr. med. (dent.) abstracts, 74% of Dr. sc. hum. abstracts; Table ​ Table1). 1 ). Individual interviews were the most common form of data collection ( n  = 80), followed by group interviews ( n  = 33) and observation ( n  = 11). In total, 23 abstracts indicated the use of a combination of different qualitative methods of data conduction, all of these included individual interviews. For documentation/recording, when reported ( n  = 37), audio recording was used in most cases ( n  = 3).

Little difference regarding method of data conduction were found between pure qualitative and mixed-methods designs. Mixed methods studies rather included physicians ( n  = 21) and used predominantly general content analysis ( n  = 14), when reported; whereas qualitative studies rather included patients ( n  = 28) and used predominantly both content analysis ( n  = 14) and content analysis following Mayring ( n  = 12). Overall incomplete reporting was more common in mixed-method studies ( n  = 41) than qualitative studies ( n  = 26, 55.3%) (see App. 2).

Sample size varied widely: Overall, 67 abstracts provided a sample size. Of those, a median number of 29 people (min-max: 2–136) participated in individual and group interviews. Only in Dr. sc. hum. dissertations using mixed methods, lower median sample sizes were reported for the qualitative part (Md = 22, min-max: 6–110; n  = 17) compared to dissertations using qualitative methods only (medical science ( n  = 7): Md = 31, min-max: 16–50; MD ( n  = 29): Md = 29, min-max: 7–136) and Dr. med. (dent.) dissertations with mixed methods (Md = 30, min-max: 2–62; n  = 14). In individual interviews, when sample size was reported ( n  = 55, 69% of 80), it distributed roughly equally in the ranges of 1–10, 11–20, 21–30, 31–50 and above 50 (Md = 25; min-max: 2–110). For the 33 dissertations using group interviews, the number of groups is given in 20 abstracts, the number of participants in 15 abstracts. Between 1 and 24 group interviews were conducted with a median total of 24 participants (min-max: 2–65) (see Table ​ Table1 1 ).

Patients ( n  = 36) and physicians ( n  = 36) were the overall most frequent research participants , followed by other health care professionals ( n  = 17), students ( n  = 11) and relatives of patients ( n  = 7). Other participants ( n  = 16) included: representatives of self-help organizations and other experts, educators such as teachers and policy makers. In 33% ( n  = 31) of the abstracts, more than one participant group was included, 6.8% ( n  = 7) did not specify research participants. While MD dissertations predominantly included physicians ( n  = 27) and patients ( n  = 19), Dr. sc. hum. dissertations included mostly patients ( n  = 17) and other participants ( n  = 10).

Data analysis

For data analysis, if reported ( n  = 57), content analyses were the most common used method ( n  = 42), including the highly deductive approach formulated by Mayring [ 26 ] ( n  = 16), mostly used in MD dissertations ( n  = 14). Among other reported methods ( n  = 15), grounded theory ( n  = 5) was the most common approach; rarely mentioned methods include framework analysis and non-specific analysis combining inductive and deductive approaches. Forty-six abstracts did not provide information on the analysis method used (38.3% of MD abstracts, 53% of medical science abstracts). If reported ( n  = 24), ATLAS.ti ( n  = 14), MAXQDA ( n  = 3) and NVivo ( n  = 3) were mentioned most frequently as qualitative data analysis programs.

In summary, 36 abstracts provided all crucial data (participants: sample size, characteristics, i.e. healthcare professional/patient; data collection and analysis method). Thus, 58% ( n  = 35) of MD dissertation abstracts and 74% ( n  = 32) of Dr. sc. hum. dissertation abstracts had at least one missing information.

The results show a low but increasing use of qualitative research methods in medical dissertations. Abstracts nearly equally referred to dissertations leading to an MD degree and medical science doctorate respectively; half of which were submitted since 2011. Qualitative methods were used in several departments, most frequently in those for general practice, public health and medical psychology mirroring an already known affinity between the objective of certain medical disciplines and perspective qualitative methods [ 27 , 28 ].

About half of the studies used qualitative research methods exclusively, the other half mixed methods: While some differences were found, due to short format and sparse information within the abstract a strict differentiation between qualitative approaches alone and combined quantitative and qualitative designs was not made. Little difference according to degree type was observed. This points to a strong shared dissertation culture, that balances and conceals differences in academic training between medical students and graduates from other, quite diverse, disciplines (e.g. from humanities, natural and social sciences) pursuing a doctorate at a medical faculty.

Limited variety in methods used

The results show a strong preference for certain methods in data conduction, research participants and data analysis: Individual and group interviews were predominant as well as content analysis, especially Mayring’s deductive approach. All in all, a limited use of the broad spectrum of qualitative research methods can be observed. Interviews are important to gain insights on actors’ perspective [ 6 ]; however, they have limited information value when it comes to actual processes and practice of health care. To investigates those, additional direct observation would be suitable [ 8 , 9 ]. In group interviews shared norms and opions can be observed, they are not suitable to capture individual perspectices. Group interviews go along with higher time and efforts regarding scheduling, interview guidance and data analysis [ 7 ]. Within the dissertations, documents are rarely used as data within the dissertations, but could be useful readily available documents.

Included research participants were mostly patients and physicians. This might be due to the research questions posed or the availability of participants. However, to reflect the complexity of health care a higher diversity of research questions, expanding participants (e.g. other health care professionals and caregivers) and based on a thorough knowledge of available methods, including qualitative approaches, might be needed.

As for methods of analysis, the results show a predominant use of a form of content analysis, with a strong affinity to quantitative analysis often limited to description forgoing in-depth analysis. As qualitative methods belong to the interpretative paradigm, most qualitative methodologies emphasize inductive analyses (e.g. Grounded Theory) and/or a combination of induction and deduction [ 12 , 29 ]. By using primarily descriptive content analysis the full potential of qualitative research and depth of the data to gain new a insights are thus neglected. Since knowledge about and application of qualitative methods are not part of the medical curriculum, doctoral students lack training in using qualitative methods and grasping the possibilities these methods convey for in-depth original knowledge.

Incomplete reporting

One fundamental principle of good research practice is accurate reporting. For empirical research, reporting on research design and methods is crucial to ensure comparability and reflect reach of research results. Within medicine and other health sciences, while debated [ 30 ], reporting guidelines are increasingly used to guarantee a basic standard. While qualitative research designs differ from clinical and quantitative designs regarding theoretical and methodological background, study aims and research process, rigorous reporting is a shared standard: this includes reporting on data conduction, sampling, participants and data analysis (e.g. COREQ [ 24 ]).

In our study, incomplete reporting regarding research design and methods was common. Especially, information on methods of data analysis was missing in about half of the abstracts reflecting the limited awareness of the plethora of qualitative analysis methods. Additionally, a third of the abstracts did not provide information on sample size. Although the importance of a “sufficient” sample size is controversially discussed, identifying the sources and putting their contributions into perspective is a paramount characteristic of qualitative research [ 31 – 33 ]. All in all, incomplete reporting was common ( n  = 67). Additionally, out of 123 initially identified abstracts, 20 had to be excluded from the analysis as comparability was not given mainly due to the inconclusive use of the term qualitative methods.

Several issues should be considered when interpreting the findings from this study. As a case study at one large faculty, which has a strong research orientation, the generalizability of the findings is uncertain. It seems unlikely that the quality of reporting is better in other medical faculties in Germany, but the prevalence of using qualitative methods might be higher. Character and role of the abstracts might not be as apparent as in journal papers, as they serve as a summary of the dissertation and are listed within the online repository databank only. The relation of reporting quality of those abstracts and the full text dissertation or even publication is unknown. Presentation of results was not assessed as information in abstracts were brief and heterogenous. Additionally, insights are limited by the structure of the repository databank itself, i.e. sub-disciplines are combined that sometimes cover distinct research fields or did evolve as separate specialties. All in all, however, the results mirror the critique on the lack of scientific training in medical education [ 17 , 22 , 34 , 35 ] and the want of sufficient reporting in medicine and health science, irrespective of study design [ 36 ].

While recent policies put a strong emphasis on strengthening scientific competences in medical education in Germany [ 15 , 21 , 22 ], especially MD dissertations are only in some degree comparable to dissertation thesis of other disciplines and medical dissertations internationally: In Germany, about 60% of all graduating medical students complete an academic dissertation [ 14 ], which they usually finish parallel to medical school within a full-time equivalent of about a year [ 15 – 18 ]. Graduate programs that exclusively dedicate 1 year for pursuing a dissertation are still discussed as innovative [ 35 ]. Additionally, the expertise of supervisors was not assessed. In a recent opinion paper, Malterud et al. [ 37 ] called for supervisors and dissertation committees holding corresponding methodological skills and experience as well as an academic consensus regarding scientific rigour to ensure high quality theses using qualitative methods. Missing standards in supervision and reporting might have led to the observed results in our study.

Qualitative research methods offer a unique scientific benefit to health care, including medicine. Our results show that within dissertation research, the number of dissertations applying qualitative methods has continually increased mirroring an overall trend in health research. To improve reach and results, a broader spectrum of qualitative methods should be considered when selecting research designs, including e.g. (direct) observation, document and analysis strategies, that combine inductive and deductive approaches. Same holds true for including a more diverse body of research participants. More broadly, reporting and academic practice should be improved.

Reporting guidelines can not only help to improve the quality of reporting but also be used as a tool to supervising graduate students steps commonly associated with qualitative research methods. So far, however, reporting guidelines mainly target full and/or published papers. Still, some reporting guidelines for abstracts are already available [ 38 – 41 ], that could be adapted for dissertation research in health science.

In academic practice, skilled supervision alongside transparent and method-appropriate criteria are the precondition for confident and courageous dissertation research that increases understanding and challenges existing knowledge of health care research. Educational programs strengthening research and reporting skills – within and beyond qualitative methods – should be implemented into medical education more profoundly, at the latest in doctoral training.

Acknowledgements

We would like to thank Laura Svensson for assisting in reviewing the abstracts and data extraction. In addition, we would like to thank the reviewers for their thorough review and constructive comments.

Abbreviations

Authors’ contributions.

CU and KK conceived the idea for this manuscript. CU, KK and AS reviewed, extracted and analyzed the data. KK led the data analysis. CU wrote the first draft of the manuscript. MW provided substantial comments at different stages of the manuscript. CU, KK and MW critically revised the manuscript. All authors read and approved the manuscript for submission.

Open Access funding enabled and organized by Projekt DEAL.

Availability of data and materials

Ethics approval and consent to participate.

Not applicable. In accordance with the scope and design of this study no formal study protocol was written.

Consent for publication

Not applicable.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Charlotte Ullrich, Email: [email protected] .

Anna Stürmlinger, Email: [email protected] .

Michel Wensing, Email: [email protected] .

Katja Krug, Email: [email protected] .

• Joseph Bordogna Forum
• Pender Lecture
• Berger Lecture
• Heilmeier Lecture
• Grace Hopper Lecture
• Technology, Business and Government Lecture
• Rachleff Lecture
• Commencement
• Departmental Events
• Make a Gift
• Current Students

« All Events

BE Doctoral Dissertation Defense: “Deep Learning for Unpaired Domain Adaptive Medical Image Segmentation”

April 17 at 1:00 pm - 3:00 pm, phd candidate.

• Google Calendar
• Outlook 365
• Outlook Live

Graduate students and faculty mentors honored at the Graduate School's 2024 awards reception

Cathy Grimes

• Share on Facebook
• Share on Twitter
• Copy address link to clipboard

Students and faculty were honored at the Graduate School’ s annual awards reception in late March. Held during Graduate Education Week, with its theme of recognizing superpowers, the event recognized master’s and doctoral degree students, as well as faculty mentors, from across Virginia Tech’s campuses and programs for their work.

Award winners included the graduate students of the year and students who received the service excellence award, graduate teaching excellence awards, and outstanding dissertation and thesis awards. Outstanding master’s degree and Ph.D. students chosen by each college received honors, as did faculty members chosen by the colleges.

The work of many of the award winners focused on the research they have done or are engaged in at Virginia Tech, or on teaching students in classes across the university’s programs. 

Student of the year and service awards

• Graduate Student of the Year: Roan Parrish, Ph.D. student, science, technology, and society , College of Liberal Arts and Human Sciences
• Graduate Service Excellence Award: Jiayuan Dong, Ph.D. student, industrial and systems engineering , College of Engineering

Thesis and dissertation awards

• Outstanding Science, Technology, Engineering, and Math (STEM) Dissertation Award: Yuxin Zhang, chemistry , College of Science
• Outstanding Social Sciences, Business, Education, and Humanities (SSBEH) Dissertation Awards: Tanya Mitropoulos, psychology , College of Science
• Outstanding Master’s Thesis Award, STEM: Shivani Goyal, psychology, College of Science
• Outstanding Master’s Thesis Award, SSBEH: Maguette Sembene, agriculture and applied economics , College of Agriculture and Animal Sciences

Teaching awards

• Teaching Excellence Instructor of Record Award: Reed Byg, Ph.D., political science , College of Liberal Arts and Human Sciences
• Teaching Excellence Assistant Award: Adam McNeeley, Ph.D., chemical engineering , College of Engineering

Outstanding doctoral degree students

• College of Agriculture and Life Sciences: Kayla Farrell, School of Animal Science
• College of Architecture, Arts, and Design : Christine Kelley, architecture
• College of Engineering: Neeti Gandhi, chemical engineering.
• College of Liberal Arts and Human Sciences: Kulyash Zhumadilova, science, technology, and society
• College of Natural Resources and Environment : Nicholas Corline, forest resources and environmental conservation
• College of Science: Abigail Lewis, biological sciences
• Pamplin College of Business : Charis Tucker, hospitality and tourism management
• Virginia-Maryland College of Veterinary Medicine : Pallavi Rai, biomedical and veterinary science
• Interdisciplinary doctoral student: Erin Nuckols, environmental design and planning in the College of Engineering and the bio-inspired buildings interdisciplinary program

Outstanding master's degree students

• College of Agriculture and Life Sciences: Kate Albi, biological systems engineering
• College of Architecture, Arts, and Design: Diksha Pilania, architecture
• College of Engineering: Ayden Cohn, mechanical engineering
• College of Liberal Arts and Human Sciences: Mahmut Sami Gurdal, human development and family science
• College of Natural Resources and Environment: Indunil Dharmasiri, geography
• College of Science: Julia Shapiro, mathematics
• Pamplin College of Business: Shannon Lawrence-Montes, business administration
• Virginia-Maryland College of Veterinary Medicine: Sai Navya Vadlamudi, biomedical and veterinary science

Outstanding faculty mentors

• College of Agriculture and Life Sciences: Associate Professor Donna Westfall-Rudd, agricultural, leadership, and community education
• College of Architecture, Arts, and Design: Professor Susan Piedmont-Palladino, architecture
• College of Engineering: Professor Emily Sarver, mining and minerals engineering
• College of Liberal Arts and Human Sciences: Assistant Professor Rebecca Hester, science, technology, and society
• College of Natural Resources and Environment: Associate Professor William Mark Ford, fish and wildlife conservation
• College of Science: Professor Sophia Economou, physics
• Pamplin College of Business: Associate Professor Idris Adjerid, business information technology
• Virginia-Maryland College of Veterinary Medicine: Professor Kylene Kehn-Hall, biomedical and veterinary science

For more information about the awards, visit the Graduate School’s  awards and honors webpage . 

540-231-8795

• College of Architecture, Arts, and Design
• College of Engineering
• College of Liberal Arts and Human Sciences research
• College of Natural Resources and Environment
• College of Science
• Graduate Education
• Graduate Students
• Pamplin College of Business
• Top News College of Agriculture and Life Sciences
• Transdisciplinary research
• Virginia-Maryland College of Veterinary Medicine

Related Content