how to read medical research papers

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Scientific papers can seem complicated, but they usually follow a similar template. Once you understand that template, scientific papers are easier to understand.

The template used by most scientific journals contains these sections:

• Introduction (also called Background)
• Results  (also called Findings)

The abstract is a summary of the article. Abstracts can help you quickly understand what a study is about and what the main findings are. A good abstract summarises the background to the research, the methods used, the main results and the conclusions. Abstracts should make sense on their own, without the rest of the article, as abstracts are always available to access for free, while full articles are often only available to paying subscribers. Abstracts can be "unstructured" (written in one long paragraph) or "structured" (broken down into individual section headings).

The introduction introduces the research by presenting the research question(s) or aim(s) and explaining why it is worthwhile. Introductions generally include background information about the topic being studied, and describe other relevant research. Sometimes the introduction section does not have a title.

The methods  section describes how the researchers carried out the research. It describes the broad study design (for example whether it is a randomised controlled trial, a case-control study, a survey etc.) and gives detailed descriptions of the relevant features of their specific study (for example how many people were recruited to the study, how were they recruited, how was the questionnaire developed etc.). The researchers must also describe how they measured the outcomes (i.e. in a trial of different diets, the paper might say whether fat loss was measured using a scale, calipers or other method) and how they analysed the data. A good methods section gives the reader enough detail that they could repeat the study themselves in a way that is identical to the original in every relevant way, to see if they produce similar results.

The results section (or findings section) reports the results of the study. For example, if the research involved a large quantitative survey, the results section would include information about how many people completed the survey, basic information describing those people, and statistical analysis of the answers given in the survey. If the method was a small set of qualitative interviews, the findings the authors would report what the interviewees said, using quotations from transcripts to illustrate important findings.

Where appropriate, results are shown in tables, graphs and other figures. If tables or figures are too large, or there are very many of them, they may be included on the journal website instead of the published paper. If you are reading a study on a journal website that you think has extra material available, look for a link for ‘Online Appendix’, ‘Supplementary Data’ or ‘Web Only Data’.The results section is usually for the straightforward reporting of findings, and analysis of the meanings of those findings is often saved for the discussion section. 

The discussion is where researchers discuss the meaning of their results. If they listed specific research questions in the introduction, the discussion should report the answers to those questions, or explain why they were unable to answer those questions. Researchers usually discuss the wider importance of their results are, comparing them to relevant evidence from existing research. Researchers often make suggestions about how future research could build on their findings and how relevant groups (for example doctors) might put their evidence to use. In the discussion section, researchers should discuss what, if anything, was unexpected about the findings, and discuss any limitations of the methods that the reader should be aware of. Sometimes the discussion section is followed by a short conclusion section, but often the conclusions are part of the discussion section.

At the end of the paper is the references section, which lists details of the research papers, books, reports and other sources that have been cited in the study, so that readers can find those sources to read for themselves.

Other sections that a research paper might contain include:

• Statement of funding sources – where researchers credit the people or organisations that helped fund the research. This section might be combined with the conflict of interest statement.
• Conflict of interest statement  – where researchers declare any relationships (financial or otherwise) they have that could add bias to the research.

• What is known – bullet points listing the key points that are already known about the topic.
• What this study adds – bullet points highlighting how this study adds to existing research on the topic.
• Highlights (or Key findings) – bullet points highlighting the most important messages readers should take from the research.

Once you understand how research papers are structured, it is easier to find the information that you are interested in. For example, if you have seen a headline about a new treatment that might be relevant to you, but you are curious about how similar the people in the study are to you, you can find the paper and read about the sampling strategy in the methods section.

Your Guide to Reading Scientific Papers

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Scientific papers, also called research papers or journal articles, are a way for scientists to communicate knowledge publicly. Because researchers often write these papers to share their work with others in that field, they aren’t always easy for non-scientists to understand.

But finding and reading scientific papers is easier than you might think! Part III of our Demystifying Clinical Trials series will teach you how you to find, read, understand, and think critically about scientific papers.

Journals, Articles, and How to Find Them

A journal is a periodical that regularly publishes a collection of scientific articles. For example, the New England Journal of Medicine publishes articles on general medical topics, Nature publishes on general science, the American Journal of Cardiology focuses specifically on cardiology, and many other journals publish on cancer, pediatrics, etc. Many journals require a subscription, but most also provide articles for free after a few months. (For more on the process of how articles are written and accepted for publication, you can read our earlier blog post here .)

The American Association for Cancer Research has a great review of the most common sites to search for journal articles. These sites, along with Google Scholar , allow easy searching by keyword, disease, author, title, or journal. In addition to these sites, many doctors have profile pages on their hospital’s or clinic’s website that include a list of their recent publications. This is often provided as a citation list , which is a standard format listing the author’s names, year of publication, title, journal of publication for each article. Information from the citation can be used to find a paper on one of the common journal article search websites .

Parts of a paper

Newspapers have the same regularly occurring sections in the same order (major news, local, sports, weather, etc.). Similarly, scientific papers also have the same regular sections in the same order to ensure that information is presented consistently across all journals. Most scientific papers have the following sections:

• Title and authors: The general focus of the paper, who wrote it, and where they work
• Abstract: Spoiler alert – this is an executive summary of the entire paper, including the findings and conclusion. Abstracts are always provided for free to help readers determine if they want to keep reading (or possibly pay for) the whole article.
• Introduction/Background: Reviews previous research, why this study was done, and the hypotheses the researchers had before starting.
• Methods: Explains how the research was done. This section includes details on the sample (animals, humans, adults, kids, etc.), size of the sample, new drug or treatment procedures, data collected, and more. The section is very detailed so that other scientists can replicate the study to confirm the findings, and so people know exactly what was done in case there are questions.
• Results: Extremely detailed scientific results. This section presents information on data analysis, technical facts and figures, and usually presents large amounts of statistical results in tables and graphs.
• Discussion/Conclusion: This is the reader-friendly explanation of the results section. It also usually includes discussion of any weaknesses or limitations of the study and ideas for future research.
• References/Bibliography: The citation list of previous research that informed this paper.

Most papers also include tables, graphs, and figures (pictures) to visually share important information. Journal articles are strictly limited to only a few thousand words – and a picture is worth a thousand words! In addition, it’s often easier for readers to see a picture demonstrating something like umbilical cord blood collection than to read several paragraphs and try to imagine the process.

How to Read a Scientific Journal Article

There are three main reasons people read scientific papers: 1) interest in a particular topic, 2) to gain information needed for treating patients, or 3) to inform new scientific research. With so many papers being published in so many places now, even professionals can use tips on how to efficiently read journal articles. The best suggestion comes from Dr. Subramanyam (2013) : The cardinal rule when reading papers is: Never start reading an article from the beginning to the end. It’s better to begin by identifying the conclusions of the study by reading the title and abstract.… After reading the abstract and conclusions, if the reader deems it interesting or useful, then the entire article can be read. Journal articles are not novels that must be read from start to finish. Start by reading the abstract to get an overview of the sample, what was done in the study, and what the researchers learned at the end. Then, if you want to know more or still have questions, you can read the Introduction and Discussion sections. (The Methods and Results section share extremely technical data that is most useful to other scientists in that field.)

Thinking Critically about Journal Articles

As important as knowing the sections and how to read them is thinking critically about the paper you’re reading. The article may have been peer-reviewed by experts, but there are still important questions to keep in mind.

For instance, think about the sample. How many people did the researchers collect data on? Is the paper reviewing data from thousands of people across multiple countries, or only a few patients from one hospital? Where were they from? When was the data collected (e.g., recently or more than five years ago)? If the topic or condition is rare there will be fewer people available to collect data on, but looking at the sample size is always key when thinking about the bigger picture.

Another question to keep in mind is whether the authors discussed limitations to their study. All research has strengths and weaknesses, and the authors themselves should point out not only what might have hampered their work, but also how future research can resolve the problem. Additionally, most journals require authors to submit financial disclosure statements on how the study was funded and whether or not the authors receive money from an organization that presents a conflict of interest in their work.

The HLHS Program Presents – #ResearchRecap

Finding and reading scientific papers isn’t as overwhelming, or time-consuming, as it used to be. The internet now makes it easy for scientists share their work, and for the public to find and compare results from many different studies. There’s also a new movement among scientists to better communicate their work to the public in ways that are easy to understand. Many researchers now share their work and even answer questions from the public on their social media pages.

The Todd and Karen Wanek Family Program for HLHS fully supports this initiative and is excited to announce a new regularly-occurring series – #ResearchRecap! Beginning in September, our blog and social media pages will regularly provide a brief, reader-friendly overview of new scientific papers on HLHS or related congenital heart defects. We’ll try to include papers that are available to read for free, but will always bring you the most recent and most exciting research being published. Stay tuned!

The Todd and Karen Wanek Family Program for Hypoplastic Left Heart Syndrome (HLHS) is a collaborative network of specialists bonded by the vision of finding solutions for individuals affected by congenital heart defects including HLHS. Our specialized team is addressing the various aspects of these defects by using research and clinical strategies ranging from basic science to diagnostic imaging to regenerative therapies.   Email us at [email protected] to learn more.

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How to read a paper, critical review

Reading a scientific article is a complex task. The worst way to approach this task is to treat it like the reading of a textbook—reading from title to literature cited, digesting every word along the way without any reflection or criticism.

A critical review (sometimes called a critique, critical commentary, critical appraisal, critical analysis) is a detailed commentary on and critical evaluation of a text. You might carry out a critical review as a stand-alone exercise, or as part of your research and preparation for writing a literature review. The following guidelines are designed to help you critically evaluate a research article.

How to Read a Scientific Article

You should begin by skimming the article to identify its structure and features. As you read, look for the author’s main points.

• Generate questions before, during, and after reading.
• Draw inferences based on your own experiences and knowledge.
• To really improve understanding and recall, take notes as you read.

What is meant by critical and evaluation?

• To be critical does not mean to criticise in an exclusively negative manner.   To be critical of a text means you question the information and opinions in the text, in an attempt to evaluate or judge its worth overall.
• An evaluation is an assessment of the strengths and weaknesses of a text.   This should relate to specific criteria, in the case of a research article.   You have to understand the purpose of each section, and be aware of the type of information and evidence that are needed to make it convincing, before you can judge its overall value to the research article as a whole.

Useful Downloads

• How to read a scientific paper
• How to conduct a critical review

How To Read A Paper

• Papers that go beyond numbers (qualitative research) Trisha Greenhalgh, Rod Taylor
• Papers that summarise other papers (systematic reviews and meta-analyses) Trisha Greenhalgh
• Papers that tell you what things cost (economic analyses) Trisha Greenhalgh
• Papers that report diagnostic or screening tests Trisha Greenhalgh
• Papers that report drug trials Trisha Greenhalgh
• Statistics for the non-statistician. II: “Significant” relations and their pitfalls Trisha Greenhalgh
• Statistics for the non-statistician Trisha Greenhalgh
• Assessing the methodological quality of published papers Trisha Greenhalgh
• Getting your bearings (deciding what the paper is about) Trisha Greenhalgh
• The Medline database Trisha Greenhalgh

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How to Read a Paper, the Basics of Evidence-Based Medicine

• Article contents
• Figures & tables
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Jacqueline Thompson, How to Read a Paper, the Basics of Evidence-Based Medicine, Occupational Medicine , Volume 65, Issue 2, March 2015, Page 169, https://doi.org/10.1093/occmed/kqu187

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This is the fifth edition of this book written by Prof. Greenhalgh, OBE, FRCGP, FRCP, Professor of Primary Health Care, and Dean for Research Impact, Barts and the London School of Medicine and Dentistry, London, UK. Prof. Greenhalgh is also a non-principal general practitioner in North London. The first edition was written in 1996.

The intended target audience is medical and nursing schools, but it will be of interest to any medical practitioners, allied professionals or indeed any interested person who wants to teach or learn the basics of evidence-based medicine.

The book is comprehensive and is organized into 17 chapters. They cover everything from why read papers at all, through assessing methodological quality and statistics for the non-statistician. Further chapters report on drug treatments and simple interventions, diagnostic and screening tests, systematic reviews and meta-analysis before moving on to guidelines, economic analysis, questionnaire research and finally quality improvement case studies.

Chapters that I found of particular interest were the two new chapters, Applying Evidence with Patients and Criticism of Evidence Based Medicine. I also found sections highlighting some of the misgivings with regards to meta-analysis and systematic reviews (‘lumpers’ being in favour and ‘splitters’ less so!) of value. There are also very useful appendices including a Checklist for Finding, Appraising and Implementing Evidence and Assessing the Effects of an Intervention. With the new additional chapters, the book is comprehensive, up-to-date with no obvious omissions. I feel that the text is easily access ible and well balanced. Due to its ‘easy to read’ style and compact form, this is also a book that you could use for quick referencing.

All in all, this was an engaging book while clearly remaining a text book. I only wish I had discovered it when studying for my membership exams and dissertation. It will certainly give me more confidence when reading research papers. I would recommend this to anyone who is interested in reading and understanding published research papers but who does not have a scientific background. Enjoy the read then keep for later reference.

★★★✩ (Buy and keep)

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EBM Resources: How to read a paper

Posted on 29th April 2013 by Alice Buchan

Evidence-based medicine relies on our ability to understand and interpret the data in front of us. On the BMJ   [1] website, they have a collection of articles regarding various aspects of how to approach different types of paper, and some of the specific concerns of particular types of paper, such as reviews, clinical trials, and those with qualitative data. There are also two articles regarding statistics for the non-statistician. They may be 15 years old, but the core tenets are still valid – without knowing the date I would never have known their age.

These articles are excerpts from the book How to read a paper: the basics of evidence based medicine , a sixth edition of which was published in 2019 (edited January 2022).   Each article might take 5-15 minutes to read and digest, and would be useful to anyone reading primary research papers, reviews, and meta-analyses.

http://www.bmj.com/about-bmj/resources-readers/publications/how-read-paper  [2]

[1] BMJ home page [Internet]. BMJ Group; 2013 [cited 29 April 2013]. Available from:  http://www.bmj.com/

[2] How to read a paper [Internet]. BMJ, BMJ Group; 2013 [cited 29 April 2013]. Available from:  http://www.bmj.com/about-bmj/resources-readers/publications/how-read-paper

Alice Buchan

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How to Read Research Articles Fast

• By Kevin Jubbal, M.D.
• September 23, 2021
• Accompanying Video , Medical Student , Pre-med
• Efficiency , Research

If you’re in a STEM field, chances are you’ll need to read primary literature—also known as research articles. And unlike books, effectively and efficiently reading a research paper requires a nuanced and systematic approach. In this post, I share the strategies I learned for how to read research articles fast.

When I first started reading research papers as a neuroscience major in college, it took considerable time and effort to make sense of it all. Since then, I’ve read through thousands of papers, published dozens of my own in peer reviewed journals , and can now crank through them with ease. Here’s the system I use.

1 | Determine the Purpose of Reading

Depending on the specific goal or purpose you have in reading a research paper, your approach may differ considerably. Keep that in mind as we cover the following sections.

If you’re reading a paper as a requirement for a class, like I initially had to for my neuroscience courses, you will be focusing on comprehension rather than determining utility. You’ll need to know the study hypothesis, the methods they used, the findings, and the limitations of their conclusions.

|| How to Improve Reading Comprehension — 10 Strategies ||

As you proceed with your medical training, you will likely write many of your own research articles . After all, doing so is one of the most powerful ways to stand out and strengthen your medical school or residency application.

In these instances, you are primarily referencing other research papers, and it becomes more important to quickly determine the relevance and value of the paper prior to committing to a more in-depth reading and analysis. You can also take advantage of the reference list at the end of a paper to determine which other papers are relevant to your own writing.

Now that you’ve identified your primary goal, it’s time to begin reading.

2 | Don’t Read in Order

Not every section of a research article is created equal. Unlike reading a traditional book, I don’t advise you to read a research paper in the order it’s laid out.

First, read the title and the abstract to get an overview of the paper. If you come across a word or acronym you don’t understand, stop and look it up. It’s not like a novel where you can infer the meaning and likely not see the word again. The language in research articles is generally pretty straightforward, and any terms you don’t understand are often scientific terms, which are critical to your understanding of the paper and its findings.

Next, dive into the conclusion. Again, this is a research paper, not a novel, so you’re not running into any spoilers. The conclusion effectively summarizes the most pertinent findings.

Now that you have a better idea of what the paper is about, spend as much time as you desire going over the figures, methods, results, and discussion sections. The discussion section will likely be the highest yield portion that requires the most amount of time, but to truly understand the paper, you must also go over the methods and results.

3 | Understanding Significance and Limitations

A major element to reading papers is understanding the limitations of the study, which then allows you to more accurately determine its significance.

The biggest and most widespread mistake is jumping to the conclusion and not understanding the limitations and generalizability of a study. Look at any media article summarizing “new, groundbreaking research” and you’ll see what I mean. Towards the end of the discussion section in many papers, you’ll find the author’s own interpretation of the limitations of their study. But there are always many more limitations beyond what they mention.

There are entire books dedicated to the nuances of statistics and extrapolating conclusions from research. Most people know about randomization, placebo-controlled, and single or double blinded studies, but that being said, there is still so much more nuance to it. Here are a few examples:

• Study design: is the study retrospective (looking back historically) or prospective (starting with individuals that are followed over time?) Is it case-control, cohort, or cross-sectional?
• What are the endpoints used? If the study draws conclusions about heart disease and health but only uses HDL as a surrogate marker, understand the surrogate is just that—an imperfect proxy.
• Biases. There are too many to cover, but selection , recall , sampling , confounding , procedure , lead time , and the Hawthorne effect are all biases you should familiarize yourself with.
• Basic statistical analyses: sensitivity versus specificity, normal and skewed distributions, positive and negative predictive values, etc.

4 | Organize Your Notes and Thoughts

Over time, you’ll be reading dozens or even hundreds of research papers, and it becomes a challenge to keep everything straight. Again, depending on the purpose, there are a few options to consider.

If you’re reading the article as a class assignment, I recommend you print out the paper, highlight, and annotate in the margins as needed. More recently, I have done this on an iPad with Apple pencil .

If, on the other hand, you’re reading in order to write your own paper, use a citation manager right from the beginning. EndNote is often referenced as the gold standard, but it’s pretty expensive. Mendeley is a free and quite sufficient alternative.

As soon as you begin reading papers, import them into your citation manager. In a separate Word document, begin jotting down the key points of the paper that are relevant to your own project. This document of notes will serve as the main resource from which you will begin writing your own paper. Trust me—it’s much better this way. Otherwise, you’ll spend considerable time and effort hunting for facts from the dozens of PDFs you’ve read.

5 | Proficiency in Research is a Long-Term Game

Lastly, understand that a big part of reading quickly, no matter the subject matter, is your familiarity with the subject. I started off reading neuroscience papers slowly, but as my expertise in the area grew, I was able to breeze through them. I knew the anatomy and terminology like the back of my hand, and coming across terms like CA1 vs. CA2 neurons of the hippocampus no longer required additional processing.

Similarly, when I first started diving into plastic surgery research, I didn’t know all of the nuances of hand anatomy or the principles of aesthetic surgery . But as I grew to understand more, reading and understanding the literature became second nature, and once again I was able to breeze through them.

It’s important to keep this in mind to make sure you don’t get discouraged. If you consistently apply yourself, read research articles, and follow the steps I’ve outlined, you’ll be tackling papers with ease in no time.

Like it or not, being proficient in research is an essential skill if you want to go to a top medical school or residency . There’s a science—but also an art—to bolstering a solid research CV and securing impressive letters of recommendation from your PI. You can check out my own personal list of research articles, abstracts, and presentations on my personal website at kevinjubbal.com .

Being proficient in research was a huge part of my own success getting into a top medical school and a highly competitive residency. It’s a challenging ordeal, and very few people know how to address this for maximum effectiveness. Through experimentation and uncommon techniques, I was able to create the systems that generated radically high publication rates in record time. Our Med School Insiders advisors can teach you the same systems and help you highlight your own research projects to put your work in the best possible light.

Kevin Jubbal, M.D.

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How to read a paper: Papers that go beyond numbers (qualitative research)

• Related content
• Peer review
• Trisha Greenhalgh , senior lecturer a ( p.greenhalgh{at}ucl.ac.uk ) ⇑ ,
• Rod Taylor , senior lecturer b
• a Unit for Evidence-Based Practice and Policy, Department of Primary Care and Population Sciences, University College London Medical School/Royal Free Hospital School of Medicine, Whittington Hospital, London N19 5NF
• b Exeter and Devon Research and Development Support Unit, Postgraduate Medical School, Wonford, Exeter EX2 5EQ
• Correspondence to: Dr Greenhalgh

What is qualitative research?

Epidemiologist Nick Black has argued that a finding or a result is more likely to be accepted as a fact if it is quantified (expressed in numbers) than if it is not. 1 There is little or no scientific evidence, for example, to support the well known “facts” that one couple in 10 is infertile, or that one man in 10 is homosexual. Yet, observes Black, most of us are happy to accept uncritically such simplified, reductionist, and blatantly incorrect statements so long as they contain at least one number.

Researchers who use qualitative methods seek a deeper truth. They aim to “study things in their natural setting, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them,” 2 and they use “a holistic perspective which preserves the complexities of human behaviour.” 1

Summary points

Qualitative methods aim to make sense of, or interpret, phenomena in terms of the meanings people bring to them

Qualitative research may define preliminary questions which can then be addressed in quantitative studies

A good qualitative study will address a clinical problem through a clearly formulated question and using more than one research method (triangulation)

Analysis of qualitative data can and should be done using explicit, systematic, and reproducible methods

Questions such as “How many parents would consult their general practitioner when their child has a mild temperature?” or “What proportion of smokers have tried to give up?” clearly need answering through quantitative methods. But questions like “Why do parents worry so much about their children's temperature?” and “What stops people giving up smoking?” cannot and should not be answered by leaping in and measuring the first aspect of the problem that we (the outsiders) think might be important. Rather, we need to listen to what people have to say, and we should explore the ideas and concerns which the subjects themselves come up with. After a while, we may notice a pattern emerging, which may prompt us to make our observations in a different way. We may start with one of the methods shown in box , and go on to use a selection of others.

Box 1: Examples of qualitative research methods

Documents —Study of documentary accounts of events, such as meetings

Passive observation —Systematic watching of behaviour and talk in natural occurring settings

Participant observation —Observation in which the researcher also occupies a role or part in the setting, in addition to observing

In depth interviews —Face to face conversation with the purpose of exploring issues or topics in detail. Does not use preset questions, but is shaped by a defined set of topics

Focus groups —Method of group interview which explicitly includes and uses the group interaction to generate data

Box box summarises (indeed, overstates) the differences between the qualitative and quantitative approaches to research. In reality, there is a great deal of overlap between them, the importance of which is increasingly being recognised. 4

Qualitative versus quantitative research—the overstated dichotomy

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Quantitative research should begin with an idea (usually articulated as a hypothesis), which then, through measurement, generates data and, by deduction, allows a conclusion to be drawn. Qualitative research, in contrast, begins with an intention to explore a particular area, collects “data” (observations and interviews), and generates ideas and hypotheses from these data largely through what is known as inductive reasoning. 3 The strength of the quantitative approach lies in its reliability (repeatability)—that is, the same measurements should yield the same results time after time. The strength of qualitative research lies in validity (closeness to the truth)—that is, good qualitative research, using a selection of data collection methods, really should touch the core of what is going on rather than just skimming the surface. The validity of qualitative methods is greatly improved by using a combination of research methods, a process known as triangulation, and by independent analysis of the data by more than one researcher.

The so called iterative approach (altering the research methods and the hypothesis as the study progresses, in the light of information gleaned along the way) used by qualitative researchers shows a commendable sensitivity to the richness and variability of the subject matter. Failure to recognise the legitimacy of this approach has, in the past, led critics to accuse qualitative researchers of continually moving their own goalposts. Though these criticisms are often misguided, there is, as Nicky Britten and colleagues have observed, a real danger “that the flexibility [of the iterative approach] will slide into sloppiness as the researcher ceases to be clear about what it is (s)he is investigating.” 5 These authors warn that qualitative researchers must, therefore, allow periods away from their fieldwork for reflection, planning, and consultation with colleagues.

Evaluating papers that describe qualitative research

By its very nature, qualitative research is non-standard, unconfined, and dependent on the subjective experience of both the researcher and the researched. It explores what needs to be explored and cuts its cloth accordingly. It is debatable, therefore, whether an all-encompassing critical appraisal checklist along the lines of the Users' Guides to the Medical Literature 6 7 8 9 10 11 12 13 14 15 16 17 18 19 could ever be developed. Our own view, and that of a number of individuals who have attempted, or are currently working on, this very task, 3 5 is that such a checklist may not be as exhaustive or as universally applicable as the various guides for appraising quantitative research, but that it is certainly possible to set some ground rules. The list which follows has been distilled from the published work cited earlier, 2 3 5 and also from our own research and teaching experiences. You should note, however, that there is a great deal of disagreement and debate about the appropriate criteria for critical appraisal of qualitative research, and the ones given here are likely to be modified in the future.

Question 1: Did the paper describe an important clinical problem addressed via a clearly formulated question?

A previous article in this series explained that one of the first things you should look for in any research paper is a statement of why the research was done and what specific question it addressed. 20 Qualitative papers are no exception to this rule: there is absolutely no scientific value in interviewing or observing people just for the sake of it. Papers that cannot define their topic of research more closely than “We decided to interview 20 patients with epilepsy” inspire little confidence that the researchers really knew what they were studying or why.

You might be more inclined to read on if the paper stated in its introduction something like, “Epilepsy is a common and potentially disabling condition, and up to 20% of patients do not remain free of fits while taking medication. Antiepileptic medication is known to have unpleasant side effects, and several studies have shown that a high proportion of patients do not take their tablets regularly. We therefore decided to explore patients' beliefs about epilepsy and their perceived reasons for not taking their medication.”

Question 2: Was a qualitative approach appropriate?

If the objective of the research was to explore, interpret, or obtain a deeper understanding of a particular clinical issue, qualitative methods were almost certainly the most appropriate ones to use. If, however, the research aimed to achieve some other goal (such as determining the incidence of a disease or the frequency of an adverse drug reaction, testing a cause and effect hypothesis, or showing that one drug has a better risk-benefit ratio than another), a case-control study, cohort study, or randomised trial may have been better suited to the research question. 19

Question 3: How were the setting and the subjects selected?

The second box contrasts the statistical sampling methods of quantitative research with theoretical methods of qualitative research. In quantitative research, it is vital to ensure that a truly random sample of subjects is recruited so that the results reflect, on average, the condition of the population from which that sample was drawn.

In qualitative research, however, we are not interested in an “on average” view of a patient population. We want to gain an in depth understanding of the experience of particular individuals or groups; we should therefore deliberately seek out individuals or groups who fit the bill. If, for example, we wished to study the experience of non-English speaking British Punjabi women when they gave birth in hospital (with a view to tailoring the interpreting or advocacy service more closely to the needs of this patient group), we would be perfectly justified in going out of our way to find women who had had a range of different birth experiences—an induced delivery, an emergency caesarean section, a delivery by a medical student, a late miscarriage, and so on—rather than a “random” sample of British Punjabi mothers.

Question 4: What was the researcher's perspective, and has this been taken into account?

PETER BROWN

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It is important to recognise that there is no way of abolishing, or fully controlling for, observer bias in qualitative research. This is most obviously the case when participant observation is used, but it is also true for other forms of data collection and of data analysis. If, for example, the research concerns the experience of asthmatic adults living in damp and overcrowded housing and the perceived effect of these surroundings on their health, the data generated by techniques such as focus groups or semistructured interviews are likely to be heavily influenced by what the interviewer believes about this subject and by whether he or she is employed by the hospital chest clinic, the social work department of the local authority, or an environmental pressure group. But since it is inconceivable that the interviews could have been conducted by someone with no views at all and no ideological or cultural perspective, the most that can be required of the researchers is that they describe in detail where they are coming from so that the results can be interpreted accordingly.

Question 5: What methods did the researcher use for collecting data—and are these described in enough detail?

I once spent two years doing highly quantitative, laboratory based experimental research in which around 15 hours of every week were spent filling or emptying test tubes. There was a standard way to fill the test tubes, a standard way to spin them in the centrifuge, and even a standard way to wash them up. When I finally published my research, some 900 hours of drudgery was summed up in a single sentence: “Patients' serum rhubarb levels were measured according to the method described by Bloggs et al [reference to Bloggs et al's published paper].”

The methods section of a qualitative paper often cannot be written in shorthand or dismissed by reference to someone else's research techniques. It may have to be lengthy and discursive since it is telling a unique story without which the results cannot be interpreted. As with the sampling strategy, there are no hard and fast rules about exactly what details should be included in this section of the paper. You should simply ask, “have I been given enough information about the methods used?”, and, if you have, use your common sense to assess, “are these methods a sensible and adequate way of addressing the research question?”

Question 6: What methods did the researcher use to analyse the data—and what quality control measures were implemented?

The data analysis section of a qualitative research paper is where sense can most readily be distinguished from nonsense. Having amassed a thick pile of completed interview transcripts or field notes, the genuine qualitative researcher has hardly begun. It is simply not good enough to flick through the text looking for “interesting quotes” which support a particular theory. The researcher must find a systematic way of analysing his or her data, and, in particular, must seek examples of cases which appear to contradict or challenge the theories derived from the majority.

One way of doing this is by content analysis: drawing up a list of coded categories and “cutting and pasting” each segment of transcribed data into one of these categories. This can be done either manually or, if large amounts of data are to be analysed, via a tailor-made computer database. The statements made by all the subjects on a particular topic can then be compared with one another, and more sophisticated comparisons can be made such as “did people who made statement A also tend to make statement B?”

In theory, the paper will show evidence of “quality control”—that is, the data (or at least, a sample of them) will have been analysed by more than one researcher to confirm that they are both assigning the same meaning to them, although in practice this is often difficult to achieve. Indeed, when researching this article, we could find no data on the interobserver reliability of any qualitative study to illustrate this point.

Question 7: Are the results credible, and if so, are they clinically important?

We obviously cannot assess the credibility of qualitative results through the precision and accuracy of measuring devices, nor their significance via confidence intervals and numbers needed to treat. It usually takes little more than plain common sense to determine whether the results are sensible and believable, and whether they matter in practice.

One important aspect of the results section to check is whether the authors cite actual data. Claims such as “general practitioners did not usually recognise the value of audit” would be infinitely more credible if one or two verbatim quotes from the interviewees were reproduced to illustrate them. The results should be independently and objectively verifiable—after all, a subject either made a particular statement or (s)he did not—and all quotes and examples should be indexed so that they can be traced back to an identifiable subject and setting.

Question 8: What conclusions were drawn, and are they justified by the results?

A quantitative research paper should clearly distinguish the study's results (usually a set of numbers) from the interpretation of those results (the discussion). The reader should have no difficulty separating what the researchers found from what they think it means . In qualitative research, however, such a distinction is rarely possible, since the results are by definition an interpretation of the data.

It is therefore necessary, when assessing the validity of qualitative research, to ask whether the interpretation placed on the data accords with common sense and is relatively untainted with personal or cultural perspective. This can be a difficult exercise, because the language we use to describe things tends to impugn meanings and motives which the subjects themselves may not share. Compare, for example, the two statements, “three women went to the well to get water” and “three women met at the well and each was carrying a pitcher.”

It is becoming a cliché that the conclusions of qualitative studies, like those of all research, should be “grounded in evidence”—that is, that they should flow from what the researchers found in the field. Mays and Pope suggest three useful questions for determining whether the conclusions of a qualitative study are valid:

how well does this analysis explain why people behave in the way they do?

how comprehensible would this explanation be to a thoughtful participant in the setting?; and

how well does the explanation cohere with what we already know? 3

Question 9: Are the findings of the study transferable to other clinical settings?

One of the commonest criticisms of qualitative research is that the findings of any qualitative study pertain only to the limited setting in which they were obtained. In fact, this is not necessarily any truer of qualitative research than of quantitative research. Look back at the example of British Punjabi women described above. You should be able to see that the use of a true theoretical sampling frame greatly increases the transferability of the results over a “convenience” sample.

Doctors have traditionally placed high value on numerical data, which may in reality be misleading, reductionist, and irrelevant to the real issues. The increasing popularity of qualitative research in the biomedical sciences has arisen largely because quantitative methods provided either no answers or the wrong answers to important questions in both clinical care and service delivery. 1 If you still feel that qualitative research is necessarily second rate by virtue of being a “soft” science, you should be aware that you are out of step with the evidence.

In 1993, Pope and Britten presented a paper to the BSA Medical Sociology Group conference entitled “Barriers to qualitative methods in the medical mindset,” in which they showed their collection of rejection letters from biomedical journals. The letters revealed a striking ignorance of qualitative methodology on the part of reviewers. In other words, the people who had rejected the papers often seemed to be incapable of distinguishing good qualitative research from bad. Somewhat ironically, qualitative papers of poor quality now appear regularly in some medical journals, whose editors have climbed on the qualitative bandwagon without gaining an ability to appraise such papers. Note, however, that the critical appraisal of qualitative research is a relatively underdeveloped science, and the questions posed in this chapter are still being refined.

The articles in this series are excerpts from How to read a paper: the basics of evidence based medicine . The book includes chapters on searching the literature and implementing evidence based findings. It can be ordered from the BMJ Publishing Group: tel 0171 383 6185/6245; fax 0171 383 6662. Price £13.95 UK members, £14.95 non-members.

Acknowledgments

Thanks to Professor Nick Black for advice on this article.

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