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• How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

• Search for relevant literature
• Evaluate sources
• Identify themes, debates, and gaps
• Outline the structure
• Write your literature review

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

• Quick Run-through
• Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

• Demonstrate your familiarity with the topic and its scholarly context
• Develop a theoretical framework and methodology for your research
• Position your work in relation to other researchers and theorists
• Show how your research addresses a gap or contributes to a debate
• Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

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See an example

Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

• Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
• Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
• Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
• Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

• Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
• Body image, self-perception, self-esteem, mental health
• Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

• Your university’s library catalogue
• Google Scholar
• Project Muse (humanities and social sciences)
• Medline (life sciences and biomedicine)
• EconLit (economics)
• Inspec (physics, engineering and computer science)

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

• What question or problem is the author addressing?
• What are the key concepts and how are they defined?
• What are the key theories, models, and methods?
• Does the research use established frameworks or take an innovative approach?
• What are the results and conclusions of the study?
• How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
• What are the strengths and weaknesses of the research?

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

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To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

• Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
• Themes: what questions or concepts recur across the literature?
• Debates, conflicts and contradictions: where do sources disagree?
• Pivotal publications: are there any influential theories or studies that changed the direction of the field?
• Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

• Most research has focused on young women.
• There is an increasing interest in the visual aspects of social media.
• But there is still a lack of robust research on highly visual platforms like Instagram and Snapchat—this is a gap that you could address in your own research.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

• Look at what results have emerged in qualitative versus quantitative research
• Discuss how the topic has been approached by empirical versus theoretical scholarship
• Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

• Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
• Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
• Critically evaluate: mention the strengths and weaknesses of your sources
• Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

Scribbr slides are free to use, customize, and distribute for educational purposes.

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If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

• Sampling methods
• Simple random sampling
• Stratified sampling
• Cluster sampling
• Likert scales
• Reproducibility

 Statistics

• Null hypothesis
• Statistical power
• Probability distribution
• Effect size
• Poisson distribution

Research bias

• Optimism bias
• Cognitive bias
• Implicit bias
• Hawthorne effect
• Anchoring bias
• Explicit bias

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

There are several reasons to conduct a literature review at the beginning of a research project:

• To familiarize yourself with the current state of knowledge on your topic
• To ensure that you’re not just repeating what others have already done
• To identify gaps in knowledge and unresolved problems that your research can address
• To develop your theoretical framework and methodology
• To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

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How to Conduct a Literature Review (Health Sciences and Beyond)

What is a literature review, traditional (narrative) literature review, integrative literature review, systematic reviews, meta-analysis, scoping review.

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• Systematic Reviews by Roy Brown Last Updated Oct 17, 2023 404 views this year
• Write a Literature Review by John Glover Last Updated Oct 16, 2023 2312 views this year

A literature review provides an overview of what's been written about a specific topic. There are many different types of literature reviews. They vary in terms of comprehensiveness, types of study included, and purpose. 

The other pages in this guide will cover some basic steps to consider when conducting a traditional health sciences literature review. See below for a quick look at some of the more popular types of literature reviews.

For additional information on a variety of review methods, the following article provides an excellent overview.

Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J. 2009 Jun;26(2):91-108. doi: 10.1111/j.1471-1842.2009.00848.x. Review. PubMed PMID: 19490148.

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A necessary skill for any doctor

What causes disease, which drug is best, does this patient need surgery, and what is the prognosis? Although experience helps in answering these questions, ultimately they are best answered by evidence based medicine. But how do you assess the evidence? As a medical student, and throughout your career as a doctor, critical appraisal of published literature is an important skill to develop and refine. At medical school you will repeatedly appraise published literature and write literature reviews. These activities are commonly part of a special study module, research project for an intercalated degree, or another type of essay based assignment.

Formulating a question

Literature reviews are most commonly performed to help answer a particular question. While you are at medical school, there will usually be some choice regarding the area you are going to review.

Once you have identified a subject area for review, the next step is to formulate a specific research question. This is arguably the most important step because a clear question needs to be defined from the outset, which you aim to answer by doing the review. The clearer the question, the more likely it is that the answer will be clear too. It is important to have discussions with your supervisor when formulating a research question as his or her input will be invaluable. The research question must be objective and concise because it is easier to search through the evidence with a clear question. The question also needs to be feasible. What is the point in having a question for which no published evidence exists? Your supervisor’s input will ensure you are not trying to answer an unrealistic question. Finally, is the research question clinically important? There are many research questions that may be answered, but not all of them will be relevant to clinical practice. The research question we will use as an example to work through in this article is, “What is the evidence for using angiotensin converting enzyme (ACE) inhibitors in patients with hypertension?”

Collecting the evidence

After formulating a specific research question for your literature review, the next step is to collect the evidence. Your supervisor will initially point you in the right direction by highlighting some of the more relevant papers published. Before doing the literature search it is important to agree a list of keywords with your supervisor. A source of useful keywords can be obtained by reading Cochrane reviews or other systematic reviews, such as those published in the BMJ . 1 2 A relevant Cochrane review for our research question on ACE inhibitors in hypertension is that by Heran and colleagues. 3 Appropriate keywords to search for the evidence include the words used in your research question (“angiotensin converting enzyme inhibitor,” “hypertension,” “blood pressure”), details of the types of study you are looking for (“randomised controlled trial,” “case control,” “cohort”), and the specific drugs you are interested in (that is, the various ACE inhibitors such as “ramipril,” “perindopril,” and “lisinopril”).

Once keywords have been agreed it is time to search for the evidence using the various electronic medical databases (such as PubMed, Medline, and EMBASE). PubMed is the largest of these databases and contains online information and tutorials on how to do literature searches with worked examples. Searching the databases and obtaining the articles are usually free of charge through the subscription that your university pays. Early consultation with a medical librarian is important as it will help you perform your literature search in an impartial manner, and librarians can train you to do these searches for yourself.

Literature searches can be broad or tailored to be more specific. With our example, a broad search would entail searching all articles that contain the words “blood pressure” or “ACE inhibitor.” This provides a comprehensive list of all the literature, but there are likely to be thousands of articles to review subsequently (fig 1). ⇓ In contrast, various search restrictions can be applied on the electronic databases to filter out papers that may not be relevant to your review. Figure 2 gives an example of a specific search. ⇓ The search terms used in this case were “angiotensin converting enzyme inhibitor” and “hypertension.” The limits applied to this search were all randomised controlled trials carried out in humans, published in the English language over the last 10 years, with the search terms appearing in the title of the study only. Thus the more specific the search strategy, the more manageable the number of articles to review (fig 3), and this will save you time. ⇓ However, this method risks your not identifying all the evidence in the particular field. Striking a balance between a broad and a specific search strategy is therefore important. This will come with experience and consultation with your supervisor. It is important to note that evidence is continually becoming available on these electronic databases and therefore repeating the same search at a later date can provide new evidence relevant to your review.

Fig 1 Results from a broad literature search using the term “angiotensin converting enzyme inhibitor”

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Fig 2 Example of a specific literature search. The search terms used were “angiotensin converting enzyme inhibitor” and “hypertension.” The limits applied to this search were all randomised controlled trials carried out in humans, published in English over the past 10 years, with the search terms appearing in the title of the study only

Fig 3 Results from a specific literature search (using the search terms and limits from figure 2)

Reading the abstracts (study summary) of the articles identified in your search may help you decide whether the study is applicable for your review—for example, the work may have been carried out using an animal model rather than in humans. After excluding any inappropriate articles, you need to obtain the full articles of studies you have identified. Additional relevant articles that may not have come up in your original search can also be found by searching the reference lists of the articles you have already obtained. Once again, you may find that some articles are still not applicable for your review, and these can also be excluded at this stage. It is important to explain in your final review what criteria you used to exclude articles as well as those criteria used for inclusion.

The National Institute for Health and Clinical Excellence (NICE) publishes evidence based guidelines for the United Kingdom and therefore provides an additional resource for identifying the relevant literature in a particular field. 4 NICE critically appraises the published literature with recommendations for best clinical practice proposed and graded based on the quality of evidence available. Similarly, there are internationally published evidence based guidelines, such as those produced by the European Society of Cardiology and the American College of Chest Physicians, which can be useful when collecting the literature in a particular field. 5 6

Appraising the evidence

Once you have collected the evidence, you need to critically appraise the published material. Box 1 gives definitions of terms you will encounter when reading the literature. A brief guide of how to critically appraise a study is presented; however, it is advisable to consult the references cited for further details.

Box 1: Definitions of common terms in the literature 7

Prospective—collecting data in real time after the study is designed

Retrospective—analysis of data that have already been collected to determine associations between exposure and outcome

Hypothesis—proposed association between exposure and outcome. If presented in the negative it is called the null hypothesis

Variable—a quantity or quality that changes during the study and can be measured

Single blind—subjects are unaware of their treatment, but clinicians are aware

Double blind—both subjects and clinicians are unaware of treatment given

Placebo—a simulated medical intervention, with subjects not receiving the specific intervention or treatment being studied

Outcome measure/endpoint—clinical variable or variables measured in a study subsequently used to make conclusions about the original interventions or treatments administered

Bias—difference between reported results and true results. Many types exist (such as selection, allocation, and reporting biases)

Probability (P) value—number between 0 and 1 providing the likelihood the reported results occurred by chance. A P value of 0.05 means there is a 5% likelihood that the reported result occurred by chance

Confidence intervals—provides a range between two numbers within which one can be certain the results lie. A confidence interval of 95% means one can be 95% certain the actual results lie within the reported range

The study authors should clearly define their research question and ideally the hypothesis to be tested. If the hypothesis is presented in the negative, it is called the null hypothesis. An example of a null hypothesis is smoking does not cause lung cancer. The study is then performed to assess the significance of the exposure (smoking) on outcome (lung cancer).

A major part of the critical appraisal process is to focus on study methodology, with your key task being an assessment of the extent to which a study was susceptible to bias (the discrepancy between the reported results and the true results). It should be clear from the methods what type of study was performed (box 2).

Box 2: Different study types 7

Systematic review/meta-analysis—comprehensive review of published literature using predefined methodology. Meta-analyses combine results from various studies to give numerical data for the overall association between variables

Randomised controlled trial—random allocation of patients to one of two or more groups. Used to test a new drug or procedure

Cohort study—two or more groups followed up over a long period, with one group exposed to a certain agent (drug or environmental agent) and the other not exposed, with various outcomes compared. An example would be following up a group of smokers and a group of non-smokers with the outcome measure being the development of lung cancer

Case-control study—cases (those with a particular outcome) are matched as closely as possible (for age, sex, ethnicity) with controls (those without the particular outcome). Retrospective data analysis is performed to determine any factors associated with developing the particular outcomes

Cross sectional study—looks at a specific group of patients at a single point in time. Effectively a survey. An example is asking a group of people how many of them drink alcohol

Case report—detailed reports concerning single patients. Useful in highlighting adverse drug reactions

There are many different types of bias, which depend on the particular type of study performed, and it is important to look for these biases. Several published checklists are available that provide excellent resources to help you work through the various studies and identify sources of bias. The CONSORT statement (which stands for CONsolidated Standards Of Reporting Trials) provides a minimum set of recommendations for reporting randomised controlled trials and comprises a rigorous 25 item checklist, with variations available for other study types. 8 9 As would be expected, most (17 of 25) of the items focus on questions relating to the methods and results of the randomised trial. The remaining items relate to the title, abstract, introduction, and discussion of the study, in addition to questions on trial registration, protocol, and funding.

Jadad scoring provides a simple and validated system to assess the methodological quality of a randomised clinical trial using three questions. 10 The score ranges from zero to five, with one point given for a “yes” in each of the following questions. (1) Was the study described as randomised? (2) Was the study described as double blind? (3) Were there details of subject withdrawals, exclusions, and dropouts? A further point is given if (1) the method of randomisation was appropriate, and (2) the method of blinding was appropriate.

In addition, the Critical Appraisal Skills Programme provides excellent tools for assessing the evidence in all study types (box 2). 11 The Oxford Centre for Evidence-Based Medicine levels of evidence is yet another useful resource for assessing the methodological quality of all studies. 12

Ensure all patients have been accounted for and any exclusions, for whatever reason, are reported. Knowing the baseline demographic (age, sex, ethnicity) and clinical characteristics of the population is important. Results are usually reported as probability values or confidence intervals (box 1).

This should explain the major study findings, put the results in the context of the published literature, and attempt to account for any variations from previous work. Study limitations and sources of bias should be discussed. Authors’ conclusions should be supported by the study results and not unnecessarily extrapolated. For example, a treatment shown to be effective in animals does not necessarily mean it will work in humans.

The format for writing up the literature review usually consists of an abstract (short structured summary of the review), the introduction or background, methods, results, and discussion with conclusions. There are a number of good examples of how to structure a literature review and these can be used as an outline when writing your review. 13 14

The introduction should identify the specific research question you intend to address and briefly put this into the context of the published literature. As you have now probably realised, the methods used for the review must be clear to the reader and provide the necessary detail for someone to be able to reproduce the search. The search strategy needs to include a list of keywords used, which databases were searched, and the specific search limits or filters applied. Any grading of methodological quality, such as the CONSORT statement or Jadad scoring, must be explained in addition to any study inclusion or exclusion criteria. 6 7 8 The methods also need to include a section on the data collected from each of the studies, the specific outcomes of interest, and any statistical analysis used. The latter point is usually relevant only when performing meta-analyses.

The results section must clearly show the process of filtering down from the articles obtained from the original search to the final studies included in the review—that is, accounting for all excluded studies. A flowchart is usually best to illustrate this. Next should follow a brief description of what was done in the main studies, the number of participants, the relevant results, and any potential sources of bias. It is useful to group similar studies together as it allows comparisons to be made by the reader and saves repetition in your write-up. Boxes and figures should be used appropriately to illustrate important findings from the various studies.

Finally, in the discussion you need to consider the study findings in light of the methodological quality—that is, the extent of potential bias in each study that may have affected the study results. Using the evidence, you need to make conclusions in your review, and highlight any important gaps in the evidence base, which need to be dealt with in future studies. Working through drafts of the literature review with your supervisor will help refine your critical appraisal skills and the ability to present information concisely in a structured review article. Remember, if the work is good it may get published.

Originally published as: Student BMJ 2012;20:e404

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

• ↵ The Cochrane Library. www3.interscience.wiley.com/cgibin/mrwhome/106568753/HOME?CRETRY=1&SRETRY=0 .
• ↵ British Medical Journal . www.bmj.com/ .
• ↵ Heran BS, Wong MMY, Heran IK, Wright JM. Blood pressure lowering efficacy of angiotensin converting enzyme (ACE) inhibitors for primary hypertension. Cochrane Database Syst Rev 2008 ; 4 : CD003823 , doi: 10.1002/14651858.CD003823.pub2. OpenUrl PubMed
• ↵ National Institute for Health and Clinical Excellence. www.nice.org.uk .
• ↵ European Society of Cardiology. www.escardio.org/guidelines .
• ↵ Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th ed). Chest 2008 ; 133 : 381 -453S. OpenUrl CrossRef
• ↵ Wikipedia. http://en.wikipedia.org/wiki .
• ↵ Moher D, Schulz KF, Altman DG, Egger M, Davidoff F, Elbourne D, et al. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials. Lancet 2001 ; 357 : 1191 -4. OpenUrl CrossRef PubMed Web of Science
• ↵ The CONSORT statement. www.consort-statement.org/ .
• ↵ Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996 ; 17 : 1 -12. OpenUrl CrossRef PubMed Web of Science
• ↵ Critical Appraisal Skills Programme (CASP). www.sph.nhs.uk/what-we-do/public-health-workforce/resources/critical-appraisals-skills-programme .
• ↵ Oxford Centre for Evidence-based Medicine—Levels of Evidence. www.cebm.net .
• ↵ Van den Bruel A, Thompson MJ, Haj-Hassan T, Stevens R, Moll H, Lakhanpaul M, et al . Diagnostic value of laboratory tests in identifying serious infections in febrile children: systematic review. BMJ 2011 ; 342 : d3082 . OpenUrl Abstract / FREE Full Text
• ↵ Awopetu AI, Moxey P, Hinchliffe RJ, Jones KG, Thompson MM, Holt PJ. Systematic review and meta-analysis of the relationship between hospital volume and outcome for lower limb arterial surgery. Br J Surg 2010 ; 97 : 797 -803. OpenUrl CrossRef PubMed

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• 04 December 2020
• Correction 09 December 2020

How to write a superb literature review

Andy Tay is a freelance writer based in Singapore.

You can also search for this author in PubMed   Google Scholar

Literature reviews are important resources for scientists. They provide historical context for a field while offering opinions on its future trajectory. Creating them can provide inspiration for one’s own research, as well as some practice in writing. But few scientists are trained in how to write a review — or in what constitutes an excellent one. Even picking the appropriate software to use can be an involved decision (see ‘Tools and techniques’). So Nature asked editors and working scientists with well-cited reviews for their tips.

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doi: https://doi.org/10.1038/d41586-020-03422-x

Interviews have been edited for length and clarity.

Updates & Corrections

Correction 09 December 2020 : An earlier version of the tables in this article included some incorrect details about the programs Zotero, Endnote and Manubot. These have now been corrected.

Hsing, I.-M., Xu, Y. & Zhao, W. Electroanalysis 19 , 755–768 (2007).

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Ledesma, H. A. et al. Nature Nanotechnol. 14 , 645–657 (2019).

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Brahlek, M., Koirala, N., Bansal, N. & Oh, S. Solid State Commun. 215–216 , 54–62 (2015).

Choi, Y. & Lee, S. Y. Nature Rev. Chem . https://doi.org/10.1038/s41570-020-00221-w (2020).

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YSN Doctoral Programs: Steps in Conducting a Literature Review

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• Steps in Conducting a Literature Review

What is a literature review?

A literature review is an integrated analysis -- not just a summary-- of scholarly writings and other relevant evidence related directly to your research question.  That is, it represents a synthesis of the evidence that provides background information on your topic and shows a association between the evidence and your research question.

A literature review may be a stand alone work or the introduction to a larger research paper, depending on the assignment.  Rely heavily on the guidelines your instructor has given you.

Why is it important?

A literature review is important because it:

• Explains the background of research on a topic.
• Demonstrates why a topic is significant to a subject area.
• Discovers relationships between research studies/ideas.
• Identifies major themes, concepts, and researchers on a topic.
• Identifies critical gaps and points of disagreement.
• Discusses further research questions that logically come out of the previous studies.

APA7 Style resources

APA Style Blog - for those harder to find answers

1. Choose a topic. Define your research question.

Your literature review should be guided by your central research question.  The literature represents background and research developments related to a specific research question, interpreted and analyzed by you in a synthesized way.

• Make sure your research question is not too broad or too narrow.  Is it manageable?
• Begin writing down terms that are related to your question. These will be useful for searches later.
• If you have the opportunity, discuss your topic with your professor and your class mates.

2. Decide on the scope of your review

How many studies do you need to look at? How comprehensive should it be? How many years should it cover? 

• This may depend on your assignment.  How many sources does the assignment require?

3. Select the databases you will use to conduct your searches.

Make a list of the databases you will search. 

Where to find databases:

• use the tabs on this guide
• Find other databases in the Nursing Information Resources web page
• More on the Medical Library web page
• ... and more on the Yale University Library web page

4. Conduct your searches to find the evidence. Keep track of your searches.

• Use the key words in your question, as well as synonyms for those words, as terms in your search. Use the database tutorials for help.
• Save the searches in the databases. This saves time when you want to redo, or modify, the searches. It is also helpful to use as a guide is the searches are not finding any useful results.
• Review the abstracts of research studies carefully. This will save you time.
• Use the bibliographies and references of research studies you find to locate others.
• Check with your professor, or a subject expert in the field, if you are missing any key works in the field.
• Ask your librarian for help at any time.
• Use a citation manager, such as EndNote as the repository for your citations. See the EndNote tutorials for help.

Review the literature

Some questions to help you analyze the research:

• What was the research question of the study you are reviewing? What were the authors trying to discover?
• Was the research funded by a source that could influence the findings?
• What were the research methodologies? Analyze its literature review, the samples and variables used, the results, and the conclusions.
• Does the research seem to be complete? Could it have been conducted more soundly? What further questions does it raise?
• If there are conflicting studies, why do you think that is?
• How are the authors viewed in the field? Has this study been cited? If so, how has it been analyzed?

Tips: 

• Review the abstracts carefully.  
• Keep careful notes so that you may track your thought processes during the research process.
• Create a matrix of the studies for easy analysis, and synthesis, across all of the studies.
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• Types of Literature Reviews
• How to Write a Literature Review
• How to Write the Introduction to a Research Article
• The Pandora's Box of Evidence Synthesis and the case for a living Evidence Synthesis Taxonomy | BMJ Evidence-Based Medicine, 2023
• Meeting the review family: exploring review types and associated information retrieval requirements | Health Information and Libraries Journal, 2019
• A typology of reviews: an analysis of 14 review types and associated methodologies | Health Information and Libraries Journal, 2009
• Conceptual recommendations for selecting the most appropriate knowledge synthesis method to answer research questions related to complex evidence | Journal of Clinical Epidemiology, 2016
• Methods for knowledge synthesis: an overview | Heart & Lung: The Journal of Critical Care, 2014
• Not sure what type of review to conduct? Brief descriptions of each type plus tools to help you decide

• Ten simple rules for writing a literature review | PLoS Computational Biology, 2013
• The Purpose, Process, and Methods of Writing a Literature Review | AORN Journal. 2016
• Why, When, Who, What, How, and Where for Trainees Writing Literature Review Articles. | Annals of Biomed Engineering, 2019
• So You Want to Write a Narrative Review Article? | Journal of Cardiothoracic and Anesthesia, 2021
• An Introduction to Writing Narrative and Systematic Reviews - Tasks, Tips and Traps for Aspiring Authors | Heart, Lung, and Circulation, 2018

• The Literature Review: A Foundation for High-Quality Medical Education Research | Journal of Graduate Medical Education, 2016
• Writing an effective literature review : Part I: Mapping the gap | Perspectives on Medical Education, 2018
• Writing an effective literature review : Part II: Citation technique | Perspectives on Medical Education, 2018
• Last Updated: Apr 15, 2024 10:20 PM
• URL: https://guides.lib.utexas.edu/medicine

Home » Office of Curriculum » Medical Student Scholarship » III Scholarship Start Here » Scholarship of Integration » Key Steps in a Literature Review

Key Steps in a Literature Review

The 5 key steps  below are most relevant to narrative reviews. Systematic reviews include the additional step of using a standardized scoring system to assess the quality of each article. More information on  Step 1 can be found  here  and Step 5  here .

• Consider the purpose and rationale of a review
• Clearly articulate the components of the question
• The research question and purpose of your review should guide the development of your search strategy (i.e. which databases to search and which search terms to use)
• Justify any limitations you create for your search,
• Determine inclusion and exclusion criteria.
• Start by reviewing abstracts for relevant articles. Once this is complete, then begin a full text review of the remaining articles.
• Develop a data-charting form to extract data from each article. Update this form as needed if you find there is more information worth collecting.
• The resulting forms will serve as a summary of each article that will facilitate the process of synthesizing your results (i.e. the selected articles).
• In your analysis, include a numerical summary of studies included, an evidence table summarizing included articles, and a qualitative summary of the results.
• Report the results in the context of the overall purpose or research question.
• Consider the meaning of your results. Discuss limitations and implications for future research, practice, and/or policy.

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How to Write a Systematic Review of the Literature

Affiliations.

• 1 1 Texas Tech University, Lubbock, TX, USA.
• 2 2 University of Florida, Gainesville, FL, USA.
• PMID: 29283007
• DOI: 10.1177/1937586717747384

This article provides a step-by-step approach to conducting and reporting systematic literature reviews (SLRs) in the domain of healthcare design and discusses some of the key quality issues associated with SLRs. SLR, as the name implies, is a systematic way of collecting, critically evaluating, integrating, and presenting findings from across multiple research studies on a research question or topic of interest. SLR provides a way to assess the quality level and magnitude of existing evidence on a question or topic of interest. It offers a broader and more accurate level of understanding than a traditional literature review. A systematic review adheres to standardized methodologies/guidelines in systematic searching, filtering, reviewing, critiquing, interpreting, synthesizing, and reporting of findings from multiple publications on a topic/domain of interest. The Cochrane Collaboration is the most well-known and widely respected global organization producing SLRs within the healthcare field and a standard to follow for any researcher seeking to write a transparent and methodologically sound SLR. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), like the Cochrane Collaboration, was created by an international network of health-based collaborators and provides the framework for SLR to ensure methodological rigor and quality. The PRISMA statement is an evidence-based guide consisting of a checklist and flowchart intended to be used as tools for authors seeking to write SLR and meta-analyses.

Keywords: evidence based design; healthcare design; systematic literature review.

• Evidence-Based Medicine* / organization & administration
• Research Design*
• Systematic Reviews as Topic*

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Searching the public health & medical literature more effectively: literature review help.

• Getting Started
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Writing Guides, Manuals, etc.

Literature Review Tips Handouts

Write about something you are passionate about!

• About Literature Reviews (pdf)
• Literature Review Workflow (pdf)
• Search Tips/Search Operators
• Quick Article Evaluation Worksheet (docx)
• Tips for the Literature Review Workflow
• Sample Outline for a Literature Review (docx)

Ten simple rules for writing a literature review . Pautasso M. PLoS Comput Biol. 2013;9(7):e1003149. doi:10.1371/journal.pcbi.1003149

Conducting the Literature Search . Chapter 4 of Chasan-Taber L. Writing Dissertation and Grant Proposals: Epidemiology, Preventive Medicine and Biostatistics. New York: Chapman and Hall/CRC, 2014.

A step-by-step guide to writing a research paper, from idea to full manuscript . Excellent and easy to follow blog post by Dr. Raul Pacheco-Vega.

Data Extraction

Data extraction answers the question “what do the studies tell us?”

At a minimum, consider the following when extracting data from the studies you are reviewing ( source ):

• Only use the data elements relevant to your question;
• Use a table, form, or tool (such as Covidence ) for data extraction;
• Test your methods and tool for missing data elements, redundancy, consistency, clarity.

Here is a table of data elements to consider for your data extraction. (From University of York, Centre for Reviews and Dissemination).

Critical Reading

As you read articles, write notes. You may wish to create a table, answering these questions:

• What is the hypothesis?
• What is the method? Rigorous? Appropriate sample size? Results support conclusions?
• What are the key findings?
• How does this paper support/contradict other work?
• How does it support/contradict your own approach?
• How significant is this research? What is its special contribution?
• Is this research repeating existing approaches or making a new contribution?
• What are its strengths?
• What are its weaknesses/limitations?

From: Kearns, H. & Finn, J. (2017) Supervising PhD Students: A Practical Guide and Toolkit . AU: Thinkwell, p. 103.

Submitting to a Journal? First Identify Journals That Publish on Your Topic

Through Scopus

• Visit the  Scopus database.
• Search for recent articles on your research topic.
• Above the results, click “Analyze search results."
• Click in the "Documents per year by source" box.
• On the left you will see the results listed by the number of articles published on your research topic per journal.

Through Web of Science

• Visit the Web of Science database.
• In the results, click "Analyze Results" on the right hand side.
• From the drop-down menu near the top left, choose "Publication Titles."
• Change the "Minimum record count (threshold)," if desired.
• Scroll down for a table of results by journal title.
• JANE (Journal/Author Name Estimator) Use JANE to help you discover and decide where to publish an article you have authored. Jane matches the abstract of your article to the articles in Medline to find the best matching journals (or authors, or articles).
• Jot (Journal Targeter) Jot uses Jane and other data to determine journals likely to publish your article (based on title, abstract, references) against the impact metric of those journals. From Yale University.
• EndNote Manuscript Matcher Using algorithms and data from the Web of Science and Journal Citation Reports, Manuscript Matcher identifies the most relevant and impactful journals to which one may wish to submit a manuscript. Access Manuscript Matcher via EndNote X9 or EndNote 20.
• DOAJ (Directory of Open Access Journals) Journal Lookup Look up a journal title on DOAJ and find information on publication fees, aims and scope, instructions for authors, submission to publication time, copyright, and more.

Writing Help @UCB

Here is a short list of sources of writing help available to UC Berkeley students, staff, and faculty:

• Purdue OWL Excellent collection of guides on writing, including citing/attribution, citation styles, grammar and punctuation, academic writing, and much more.
• Berkeley Writing: College Writing Programs "Our philosophy includes small class size, careful attention to building your critical reading and thinking skills along with your writing, personalized attention, and a great deal of practice writing and revising." Website has a Writing Resources Database .
• Graduate Writing Center, Berkeley Graduate Division Assists graduate students in the development of academic skills necessary to successfully complete their programs and prepare for future positions. Workshops and online consultations are offered on topics such as academic writing, grant writing, dissertation writing , thesis writing , editing, and preparing articles for publication, in addition to writing groups and individual consultations.
• Nature Masterclass on Scientific Writing and Publishing For Postdocs, Visiting Scholars, and Visiting Student Researchers with active, approved appointments, and current UC Berkeley graduate students who are new to publishing or wish to refresh their skills. Part 1: Writing a Research Paper; Part 2: Publishing a Research Paper; Part 3: Writing and Publishing a Review Paper. Offered by Visiting Researcher Scholar and Postdoc Affairs (VSPA) program; complete this form to gain access.

Alternative Publishing Formats

Here is some information and tips on getting your research to a broader, or to a specialized, audience

• Creating One-Page Reports One-page reports are a great way to provide a snapshot of a project’s activities and impact to stakeholders. Summarizing key facts in a format that is easily and quickly digestible engages the busy reader and can make your project stand out. From EvaluATE .
• How to write an Op-ed (Webinar) Strategies on how to write sharp op-eds for broader consumption, one of the most important ways to ensure your analysis and research is shared in the public sphere. From the Institute for Research on Public Policy .
• 10 tips for commentary writers From UC Berkeley Media Relations’ 2017 Op-Ed writing workshop.
• Journal of Science Policy and Governance JSPG publishes policy memos, op-eds, position papers, and similar items created by students.
• Writing Persuasive Policy Briefs Presentation slides from a UCB Science Policy Group session.
• 3 Essential Steps to Share Research With Popular Audiences (Inside Higher Ed) How to broaden the reach and increase the impact of your academic writing. Popular writing isn’t a distraction from core research!

The Politics of Citation

"One of the feminist practices key to my teaching and research is a feminist practice of citation."

From The Digital Feminist Collective , this blog post emphasizes the power of citing.

"Acknowledging and establishing feminist genealogies is part of the work of producing more just forms of knowledge and intellectual practice."

Here's an exercise (docx) to help you in determining how inclusive you are when citing.

Additional Resources for Inclusive Citation Practices :

• BIPOC Scientists Citation guide (Rockefeller Univ.).
• Conducting Research through an Anti-Racism Lens (Univ. of Minnesota Libraries).
• cleanBib (Code to probabilistically assign gender and race proportions of first/last authors pairs in bibliography entries).
• Balanced Citer (Python script guesses the race and gender of the first and last authors for papers in your citation list and compares your list to expected distributions based on a model that accounts for paper characteristics).
• Read Black women's work;
• Integrate Black women into the CORE of your syllabus (in life & in the classroom);
• Acknowledge Black women's intellectual production;
• Make space for Black women to speak;
• Give Black women the space and time to breathe.
• CiteASista .
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• Last Updated: Apr 8, 2024 5:06 PM
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Medicine Guide: Literature Reviews

• Getting Started
• Use the Library This link opens in a new window
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• Resources for Writing a Thesis
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• Finding Statistics
• Working in Groups
• Using Reference Materials

Writing the Literature Review (Part 1)

Writing the Literature Review (Part 2)

Writing a literature review

Your Liaison Librarian will be able to provide support and advice when you are doing your literature review, so make an appointment with your librarian when you start your research.

• Liaison Librarians
• Literature review template
• The Literature Review Library Guide

Literature review books @ JCU Library

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• Last Updated: Apr 16, 2024 2:32 PM
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JAY SIWEK, M.D., MARGARET L. GOURLAY, M.D., DAVID C. SLAWSON, M.D., AND ALLEN F. SHAUGHNESSY, PHARM.D.

Am Fam Physician. 2002;65(2):251-258

Traditional clinical review articles, also known as updates, differ from systematic reviews and meta-analyses. Updates selectively review the medical literature while discussing a topic broadly. Nonquantitative systematic reviews comprehensively examine the medical literature, seeking to identify and synthesize all relevant information to formulate the best approach to diagnosis or treatment. Meta-analyses (quantitative systematic reviews) seek to answer a focused clinical question, using rigorous statistical analysis of pooled research studies. This article presents guidelines for writing an evidence-based clinical review article for American Family Physician . First, the topic should be of common interest and relevance to family practice. Include a table of the continuing medical education objectives of the review. State how the literature search was done and include several sources of evidence-based reviews, such as the Cochrane Collaboration, BMJ's Clinical Evidence , or the InfoRetriever Web site. Where possible, use evidence based on clinical outcomes relating to morbidity, mortality, or quality of life, and studies of primary care populations. In articles submitted to American Family Physician , rate the level of evidence for key recommendations according to the following scale: level A (randomized controlled trial [RCT], meta-analysis); level B (other evidence); level C (consensus/expert opinion). Finally, provide a table of key summary points.

American Family Physician is particularly interested in receiving clinical review articles that follow an evidence-based format. Clinical review articles, also known as updates, differ from systematic reviews and meta-analyses in important ways. 1 Updates selectively review the medical literature while discussing a topic broadly. An example of such a topic is, “The diagnosis and treatment of myocardial ischemia.” Systematic reviews comprehensively examine the medical literature, seeking to identify and synthesize all relevant information to formulate the best approach to diagnosis or treatment. Examples are many of the systematic reviews of the Cochrane Collaboration or BMJ's Clinical Evidence compendium. Meta-analyses are a special type of systematic review. They use quantitative methods to analyze the literature and seek to answer a focused clinical question, using rigorous statistical analysis of pooled research studies. An example is, “Do beta blockers reduce mortality following myocardial infarction?”

The best clinical review articles base the discussion on existing systematic reviews and meta-analyses, and incorporate all relevant research findings about the management of a given disorder. Such evidence-based updates provide readers with powerful summaries and sound clinical guidance.

In this article, we present guidelines for writing an evidence-based clinical review article, especially one designed for continuing medical education (CME) and incorporating CME objectives into its format. This article may be read as a companion piece to a previous article and accompanying editorial about reading and evaluating clinical review articles. 1 , 2 Some articles may not be appropriate for an evidence-based format because of the nature of the topic, the slant of the article, a lack of sufficient supporting evidence, or other factors. We encourage authors to review the literature and, wherever possible, rate key points of evidence. This process will help emphasize the summary points of the article and strengthen its teaching value.

Topic Selection

Choose a common clinical problem and avoid topics that are rarities or unusual manifestations of disease or that have curiosity value only. Whenever possible, choose common problems for which there is new information about diagnosis or treatment. Emphasize new information that, if valid, should prompt a change in clinical practice, such as the recent evidence that spironolactone therapy improves survival in patients who have severe congestive heart failure. 3 Similarly, new evidence showing that a standard treatment is no longer helpful, but may be harmful, would also be important to report. For example, patching most traumatic corneal abrasions may actually cause more symptoms and delay healing compared with no patching. 4

Searching the Literature

When searching the literature on your topic, please consult several sources of evidence-based reviews ( Table 1 ) . Look for pertinent guidelines on the diagnosis, treatment, or prevention of the disorder being discussed. Incorporate all high-quality recommendations that are relevant to the topic. When reviewing the first draft, look for all key recommendations about diagnosis and, especially, treatment. Try to ensure that all recommendations are based on the highest level of evidence available. If you are not sure about the source or strength of the recommendation, return to the literature, seeking out the basis for the recommendation.

In particular, try to find the answer in an authoritative compendium of evidence-based reviews, or at least try to find a meta-analysis or well-designed randomized controlled trial (RCT) to support it. If none appears to be available, try to cite an authoritative consensus statement or clinical guideline, such as a National Institutes of Health Consensus Development Conference statement or a clinical guideline published by a major medical organization. If no strong evidence exists to support the conventional approach to managing a given clinical situation, point this out in the text, especially for key recommendations. Keep in mind that much of traditional medical practice has not yet undergone rigorous scientific study, and high-quality evidence may not exist to support conventional knowledge or practice.

Patient-Oriented vs. Disease-Oriented Evidence

With regard to types of evidence, Shaughnessy and Slawson 5 – 7 developed the concept of Patient-Oriented Evidence that Matters (POEM), in distinction to Disease-Oriented Evidence (DOE). POEM deals with outcomes of importance to patients, such as changes in morbidity, mortality, or quality of life. DOE deals with surrogate end points, such as changes in laboratory values or other measures of response. Although the results of DOE sometimes parallel the results of POEM, they do not always correspond ( Table 2 ) . 2 When possible, use POEM-type evidence rather than DOE. When DOE is the only guidance available, indicate that key clinical recommendations lack the support of outcomes evidence. Here is an example of how the latter situation might appear in the text: “Although prostate-specific antigen (PSA) testing identifies prostate cancer at an early stage, it has not yet been proved that PSA screening improves patient survival.” (Note: PSA testing is an example of DOE, a surrogate marker for the true outcomes of importance—improved survival, decreased morbidity, and improved quality of life.)

Evaluating the Literature

Evaluate the strength and validity of the literature that supports the discussion (see the following section, Levels of Evidence). Look for meta-analyses, high-quality, randomized clinical trials with important outcomes (POEM), or well-designed, nonrandomized clinical trials, clinical cohort studies, or case-controlled studies with consistent findings. In some cases, high-quality, historical, uncontrolled studies are appropriate (e.g., the evidence supporting the efficacy of Papanicolaou smear screening). Avoid anecdotal reports or repeating the hearsay of conventional wisdom, which may not stand up to the scrutiny of scientific study (e.g., prescribing prolonged bed rest for low back pain).

Look for studies that describe patient populations that are likely to be seen in primary care rather than subspecialty referral populations. Shaughnessy and Slawson's guide for writers of clinical review articles includes a section on information and validity traps to avoid. 2

Levels of Evidence

Readers need to know the strength of the evidence supporting the key clinical recommendations on diagnosis and treatment. Many different rating systems of varying complexity and clinical relevance are described in the medical literature. Recently, the third U.S. Preventive Services Task Force (USPSTF) emphasized the importance of rating not only the study type (RCT, cohort study, case-control study, etc.), but also the study quality as measured by internal validity and the quality of the entire body of evidence on a topic. 8

While it is important to appreciate these evolving concepts, we find that a simplified grading system is more useful in AFP . We have adopted the following convention, using an ABC rating scale. Criteria for high-quality studies are discussed in several sources. 8 , 9 See the AFP Web site ( www.aafp.org/afp/authors ) for additional information about levels of evidence and see the accompanying editorial in this issue discussing the potential pitfalls and limitations of any rating system.

Level A (randomized controlled trial/meta-analysis): High-quality randomized controlled trial (RCT) that considers all important outcomes. High-quality meta-analysis (quantitative systematic review) using comprehensive search strategies.

Level B (other evidence): A well-designed, nonrandomized clinical trial. A nonquantitative systematic review with appropriate search strategies and well-substantiated conclusions. Includes lower quality RCTs, clinical cohort studies, and case-controlled studies with non-biased selection of study participants and consistent findings. Other evidence, such as high-quality, historical, uncontrolled studies, or well-designed epidemiologic studies with compelling findings, is also included.

Level C (consensus/expert opinion): Consensus viewpoint or expert opinion.

Each rating is applied to a single reference in the article, not to the entire body of evidence that exists on a topic. Each label should include the letter rating (A, B, C), followed by the specific type of study for that reference. For example, following a level B rating, include one of these descriptors: (1) nonrandomized clinical trial; (2) nonquantitative systematic review; (3) lower quality RCT; (4) clinical cohort study; (5) case-controlled study; (6) historical uncontrolled study; (7) epidemiologic study.

Here are some examples of the way evidence ratings should appear in the text:

“To improve morbidity and mortality, most patients in congestive heart failure should be treated with an angiotensin-converting enzyme inhibitor. [Evidence level A, RCT]”

“The USPSTF recommends that clinicians routinely screen asymptomatic pregnant women 25 years and younger for chlamydial infection. [Evidence level B, non-randomized clinical trial]”

“The American Diabetes Association recommends screening for diabetes every three years in all patients at high risk of the disease, including all adults 45 years and older. [Evidence level C, expert opinion]”

When scientifically strong evidence does not exist to support a given clinical recommendation, you can point this out in the following way:

“Physical therapy is traditionally prescribed for the treatment of adhesive capsulitis (frozen shoulder), although there are no randomized outcomes studies of this approach.”

Format of the Review

Introduction.

The introduction should define the topic and purpose of the review and describe its relevance to family practice. The traditional way of doing this is to discuss the epidemiology of the condition, stating how many people have it at one point in time (prevalence) or what percentage of the population is expected to develop it over a given period of time (incidence). A more engaging way of doing this is to indicate how often a typical family physician is likely to encounter this problem during a week, month, year, or career. Emphasize the key CME objectives of the review and summarize them in a separate table entitled “CME Objectives.”

The methods section should briefly indicate how the literature search was conducted and what major sources of evidence were used. Ideally, indicate what predetermined criteria were used to include or exclude studies (e.g., studies had to be independently rated as being high quality by an established evaluation process, such as the Cochrane Collaboration). Be comprehensive in trying to identify all major relevant research. Critically evaluate the quality of research reviewed. Avoid selective referencing of only information that supports your conclusions. If there is controversy on a topic, address the full scope of the controversy.

The discussion can then follow the typical format of a clinical review article. It should touch on one or more of the following subtopics: etiology, pathophysiology, clinical presentation (signs and symptoms), diagnostic evaluation (history, physical examination, laboratory evaluation, and diagnostic imaging), differential diagnosis, treatment (goals, medical/surgical therapy, laboratory testing, patient education, and follow-up), prognosis, prevention, and future directions.

The review will be comprehensive and balanced if it acknowledges controversies, unresolved questions, recent developments, other viewpoints, and any apparent conflicts of interest or instances of bias that might affect the strength of the evidence presented. Emphasize an evidence-supported approach or, where little evidence exists, a consensus viewpoint. In the absence of a consensus viewpoint, you may describe generally accepted practices or discuss one or more reasoned approaches, but acknowledge that solid support for these recommendations is lacking.

In some cases, cost-effectiveness analyses may be important in deciding how to implement health care services, especially preventive services. 10 When relevant, mention high-quality cost-effectiveness analyses to help clarify the costs and health benefits associated with alternative interventions to achieve a given health outcome. Highlight key points about diagnosis and treatment in the discussion and include a summary table of the key take-home points. These points are not necessarily the same as the key recommendations, whose level of evidence is rated, although some of them will be.

Use tables, figures, and illustrations to highlight key points, and present a step-wise, algorithmic approach to diagnosis or treatment when possible.

Rate the evidence for key statements, especially treatment recommendations. We expect that most articles will have at most two to four key statements; some will have none. Rate only those statements that have corresponding references and base the rating on the quality and level of evidence presented in the supporting citations. Use primary sources (original research, RCTs, meta-analyses, and systematic reviews) as the basis for determining the level of evidence. In other words, the supporting citation should be a primary research source of the information, not a secondary source (such as a nonsystematic review article or a textbook) that simply cites the original source. Systematic reviews that analyze multiple RCTs are good sources for determining ratings of evidence.

The references should include the most current and important sources of support for key statements (i.e., studies referred to, new information, controversial material, specific quantitative data, and information that would not usually be found in most general reference textbooks). Generally, these references will be key evidence-based recommendations, meta-analyses, or landmark articles. Although some journals publish exhaustive lists of reference citations, AFP prefers to include a succinct list of key references. (We will make more extensive reference lists available on our Web site or provide links to your personal reference list.)

You may use the following checklist to ensure the completeness of your evidence-based review article; use the source list of reviews to identify important sources of evidence-based medicine materials.

Checklist for an Evidence-Based Clinical Review Article

The topic is common in family practice, especially topics in which there is new, important information about diagnosis or treatment.

The introduction defines the topic and the purpose of the review, and describes its relevance to family practice.

A table of CME objectives for the review is included.

The review states how you did your literature search and indicates what sources you checked to ensure a comprehensive assessment of relevant studies (e.g., MEDLINE, the Cochrane Collaboration Database, the Center for Research Support, TRIP Database).

Several sources of evidence-based reviews on the topic are evaluated ( Table 1 ) .

Where possible, POEM (dealing with changes in morbidity, mortality, or quality of life) rather than DOE (dealing with mechanistic explanations or surrogate end points, such as changes in laboratory tests) is used to support key clinical recommendations ( Table 2 ) .

Studies of patients likely to be representative of those in primary care practices, rather than subspecialty referral centers, are emphasized.

Studies that are not only statistically significant but also clinically significant are emphasized; e.g., interventions with meaningful changes in absolute risk reduction and low numbers needed to treat. (See http://www.cebm.net/index.aspx?o=1116 .) 11

The level of evidence for key clinical recommendations is labeled using the following rating scale: level A (RCT/meta-analysis), level B (other evidence), and level C (consensus/expert opinion).

Acknowledge controversies, recent developments, other viewpoints, and any apparent conflicts of interest or instances of bias that might affect the strength of the evidence presented.

Highlight key points about diagnosis and treatment in the discussion and include a summary table of key take-home points.

Use tables, figures, and illustrations to highlight key points and present a step-wise, algorithmic approach to diagnosis or treatment when possible.

Emphasize evidence-based guidelines and primary research studies, rather than other review articles, unless they are systematic reviews.

The essential elements of this checklist are summarized in Table 3 .

Siwek J. Reading and evaluating clinical review articles. Am Fam Physician. 1997;55:2064-2069.

Shaughnessy AF, Slawson DC. Getting the most from review articles: a guide for readers and writers. Am Fam Physician. 1997;55:2155-60.

Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med. 1999;341:709-17.

Flynn CA, D'Amico F, Smith G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract. 1998;47:264-70.

Slawson DC, Shaughnessy AF, Bennett JH. Becoming a medical information master: feeling good about not knowing everything. J Fam Pract. 1994;38:505-13.

Shaughnessy AF, Slawson DC, Bennett JH. Becoming an information master: a guidebook to the medical information jungle. J Fam Pract. 1994;39:489-99.

Slawson DC, Shaughnessy AF. Becoming an information master: using POEMs to change practice with confidence. Patient-oriented evidence that matters. J Fam Pract. 2000;49:63-7.

Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, et al. Methods Work Group, Third U.S. Preventive Services Task Force. Current methods of the U.S. Preventive Services Task Force. A review of the process. Am J Prev Med. 2001;20(3 suppl):21-35.

CATbank topics: levels of evidence and grades of recommendations. Retrieved November 2001, from: http://www.cebm.net/ .

Saha S, Hoerger TJ, Pignone MP, Teutsch SM, Helfand M, Mandelblatt JS. for the Cost Work Group of the Third U.S. Preventive Services Task Force. The art and science of incorporating cost effectiveness into evidence-based recommendations for clinical preventive services. Am J Prev Med. 2001;20(3 suppl):36-43.

Evidence-based medicine glossary. Retrieved November 2001, from: http://www.cebm.net/index.aspx?o=1116 .

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Writing a Literature Review

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A literature review is a document or section of a document that collects key sources on a topic and discusses those sources in conversation with each other (also called synthesis ). The lit review is an important genre in many disciplines, not just literature (i.e., the study of works of literature such as novels and plays). When we say “literature review” or refer to “the literature,” we are talking about the research ( scholarship ) in a given field. You will often see the terms “the research,” “the scholarship,” and “the literature” used mostly interchangeably.

Where, when, and why would I write a lit review?

There are a number of different situations where you might write a literature review, each with slightly different expectations; different disciplines, too, have field-specific expectations for what a literature review is and does. For instance, in the humanities, authors might include more overt argumentation and interpretation of source material in their literature reviews, whereas in the sciences, authors are more likely to report study designs and results in their literature reviews; these differences reflect these disciplines’ purposes and conventions in scholarship. You should always look at examples from your own discipline and talk to professors or mentors in your field to be sure you understand your discipline’s conventions, for literature reviews as well as for any other genre.

A literature review can be a part of a research paper or scholarly article, usually falling after the introduction and before the research methods sections. In these cases, the lit review just needs to cover scholarship that is important to the issue you are writing about; sometimes it will also cover key sources that informed your research methodology.

Lit reviews can also be standalone pieces, either as assignments in a class or as publications. In a class, a lit review may be assigned to help students familiarize themselves with a topic and with scholarship in their field, get an idea of the other researchers working on the topic they’re interested in, find gaps in existing research in order to propose new projects, and/or develop a theoretical framework and methodology for later research. As a publication, a lit review usually is meant to help make other scholars’ lives easier by collecting and summarizing, synthesizing, and analyzing existing research on a topic. This can be especially helpful for students or scholars getting into a new research area, or for directing an entire community of scholars toward questions that have not yet been answered.

What are the parts of a lit review?

Most lit reviews use a basic introduction-body-conclusion structure; if your lit review is part of a larger paper, the introduction and conclusion pieces may be just a few sentences while you focus most of your attention on the body. If your lit review is a standalone piece, the introduction and conclusion take up more space and give you a place to discuss your goals, research methods, and conclusions separately from where you discuss the literature itself.

Introduction:

• An introductory paragraph that explains what your working topic and thesis is
• A forecast of key topics or texts that will appear in the review
• Potentially, a description of how you found sources and how you analyzed them for inclusion and discussion in the review (more often found in published, standalone literature reviews than in lit review sections in an article or research paper)
• Summarize and synthesize: Give an overview of the main points of each source and combine them into a coherent whole
• Analyze and interpret: Don’t just paraphrase other researchers – add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
• Critically Evaluate: Mention the strengths and weaknesses of your sources
• Write in well-structured paragraphs: Use transition words and topic sentence to draw connections, comparisons, and contrasts.

Conclusion:

• Summarize the key findings you have taken from the literature and emphasize their significance
• Connect it back to your primary research question

How should I organize my lit review?

Lit reviews can take many different organizational patterns depending on what you are trying to accomplish with the review. Here are some examples:

• Chronological : The simplest approach is to trace the development of the topic over time, which helps familiarize the audience with the topic (for instance if you are introducing something that is not commonly known in your field). If you choose this strategy, be careful to avoid simply listing and summarizing sources in order. Try to analyze the patterns, turning points, and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred (as mentioned previously, this may not be appropriate in your discipline — check with a teacher or mentor if you’re unsure).
• Thematic : If you have found some recurring central themes that you will continue working with throughout your piece, you can organize your literature review into subsections that address different aspects of the topic. For example, if you are reviewing literature about women and religion, key themes can include the role of women in churches and the religious attitude towards women.
• Qualitative versus quantitative research
• Empirical versus theoretical scholarship
• Divide the research by sociological, historical, or cultural sources
• Theoretical : In many humanities articles, the literature review is the foundation for the theoretical framework. You can use it to discuss various theories, models, and definitions of key concepts. You can argue for the relevance of a specific theoretical approach or combine various theorical concepts to create a framework for your research.

What are some strategies or tips I can use while writing my lit review?

Any lit review is only as good as the research it discusses; make sure your sources are well-chosen and your research is thorough. Don’t be afraid to do more research if you discover a new thread as you’re writing. More info on the research process is available in our "Conducting Research" resources .

As you’re doing your research, create an annotated bibliography ( see our page on the this type of document ). Much of the information used in an annotated bibliography can be used also in a literature review, so you’ll be not only partially drafting your lit review as you research, but also developing your sense of the larger conversation going on among scholars, professionals, and any other stakeholders in your topic.

Usually you will need to synthesize research rather than just summarizing it. This means drawing connections between sources to create a picture of the scholarly conversation on a topic over time. Many student writers struggle to synthesize because they feel they don’t have anything to add to the scholars they are citing; here are some strategies to help you:

• It often helps to remember that the point of these kinds of syntheses is to show your readers how you understand your research, to help them read the rest of your paper.
• Writing teachers often say synthesis is like hosting a dinner party: imagine all your sources are together in a room, discussing your topic. What are they saying to each other?
• Look at the in-text citations in each paragraph. Are you citing just one source for each paragraph? This usually indicates summary only. When you have multiple sources cited in a paragraph, you are more likely to be synthesizing them (not always, but often
• Read more about synthesis here.

The most interesting literature reviews are often written as arguments (again, as mentioned at the beginning of the page, this is discipline-specific and doesn’t work for all situations). Often, the literature review is where you can establish your research as filling a particular gap or as relevant in a particular way. You have some chance to do this in your introduction in an article, but the literature review section gives a more extended opportunity to establish the conversation in the way you would like your readers to see it. You can choose the intellectual lineage you would like to be part of and whose definitions matter most to your thinking (mostly humanities-specific, but this goes for sciences as well). In addressing these points, you argue for your place in the conversation, which tends to make the lit review more compelling than a simple reporting of other sources.

Literature Searching

In this guide.

• Introduction
• Steps for searching the literature in PubMed
• Step 1 - Formulate a search question
• Step 2- Identify primary concepts and gather synonyms
• Step 3 - Locate subject headings (MeSH)
• Step 4 - Combine concepts using Boolean operators
• Step 5 - Refine search terms and search in PubMed
• Step 6 - Apply limits

Steps for Searching the Literature

Searching is an iterative process and often requires re-evaluation and testing by adding or changing keywords and the ways they relate to each other. To guide your search development, you can follow the search steps below. For more information on each step, navigate to its matching tab on the right menu. 

1. Formulate a clear, well-defined, answerable search question

Generally, the basic literature search process begins with formulating a clear, well-defined research question. Asking the right research question is essential to creating an effective search. Your research question(s) must be well-defined and answerable. If the question is too broad, your search will yield more information than you can possibly look through.

2. Identify primary concepts and gather synonyms

Your research question will also help identify the primary search concepts. This will allow you to think about how you want the concepts to relate to each other. Since different authors use different terminology to refer to the same concept, you will need to gather synonyms and all the ways authors might express them. However, it is important to balance the terms so that the synonyms do not go beyond the scope of how you've defined them.

3. Locate subject headings (MeSH)

Subject databases like PubMed use 'controlled vocabularies' made up of subject headings that are preassigned to indexed articles that share a similar topic. These subject headings are organized hierarchically within a family tree of broader and narrower concepts. In PubMed and MEDLINE, the subject headings are called Medical Subject Headings (MeSH). By including MeSH terms in your search, you will not have to think about word variations, word endings, plural or singular forms, or synonyms. Some topics or concepts may even have more than one appropriate MeSH term. There are also times when a topic or concept may not have a MeSH term. 

4. Combine concepts using Boolean operators AND/OR

Once you have identified your search concepts, synonyms, and MeSH terms, you'll need to put them together using nesting and Boolean operators (e.g. AND, OR, NOT). Nesting uses parentheses to put search terms into groups. Boolean operators are used to combine similar and different concepts into one query. 

5. Refine search terms and search in PubMed

There are various database search tactics you can use, such as field tags to limit the search to certain fields, quotation marks for phrase searching, and proximity operators to search a number of spaces between terms to refine your search terms. The constructed search string is ready to be pasted into PubMed. 

6. Apply limits (optional)

If you're getting too many results, you can further refine your search results by using limits on the left box of the results page. Limits allow you to narrow your search by a number of facets such as year, journal name, article type, language, age, etc. 

Depending on the nature of the literature review, the complexity and comprehensiveness of the search strategies and the choice of databases can be different. Please contact the Lane Librarians if you have any questions. 

The type of information you gather is influenced by the type of information source or database you select to search. Bibliographic databases contain references to published literature, such as journal articles, conference abstracts, books, reports, government and legal publications, and patents. Literature reviews typically synthesis indexed, peer-reviewed articles (i.e. works that generally represent the latest original research and have undergone rigorous expert screening before publication), and gray literature (i.e. materials not formally published by commercial publishers or peer-reviewed journals). PubMed offers a breadth of health sciences literature and is a good starting point to locate journal articles.

What is PubMed?

PubMed is a free search engine accessing primarily the MEDLINE database of references and abstracts on life sciences and biomedical topics. Available to the public online since 1996, PubMed was developed and is maintained by the  National Center for Biotechnology Information (NCBI) , at the  U.S. National Library of Medicine (NLM) , located at the  National Institutes of Health (NIH) .

MEDLINE is the National Library of Medicine’s (NLM) premier bibliographic database that contains more than 27 million references to journal articles from more than 5,200 worldwide journals in life sciences with a concentration on biomedicine. The Literature Selection Technica Review Committee (LSTRC) reviews and selects journals for MEDLINE based on the research quality and impact of the journals. A distinctive feature of MEDLINE is that the records are indexed with NLM  Medical Subject Headings  (MeSH).

PubMed also contains citations for  PubMed Central (PMC)  articles. PMC is a full-text archive that includes articles from journals reviewed and selected by NLM for archiving (current and historical), as well as individual articles collected for archiving in compliance with funder policies.  PubMed allows users to search keywords in the bibliographic data, but not the full text of the PMC articles.

How to Access PubMed?

To access PubMed, go to the Lane Library homepage and click PubMed in "Top Resources" on the left. This PubMed link is coded with Find Fulltext @ Lane Library Stanford that links you to Lane's full-text articles online. 

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Systematically Reviewing the Literature: Building the Evidence for Health Care Quality

There are important research and non-research reasons to systematically review the literature. This article describes a step-by-step process to systematically review the literature along with links to key resources. An example of a graduate program using systematic literature reviews to link research and quality improvement practices is also provided.

Introduction

Systematic reviews that summarize the available information on a topic are an important part of evidence-based health care. There are both research and non-research reasons for undertaking a literature review. It is important to systematically review the literature when one would like to justify the need for a study, to update personal knowledge and practice, to evaluate current practices, to develop and update guidelines for practice, and to develop work related policies. 1 A systematic review draws upon the best health services research principles and methods to address: What is the state of the evidence on the selected topic? The systematic process enables others to reproduce the methods and to make a rational determination of whether to accept the results of the review. An abundance of articles on systematic reviews exist focusing on different aspects of systematic reviews. 2 – 9 The purpose of this article is to describe a step by step process of systematically reviewing the health care literature and provide links to key resources.

Systematic Review Process: Six Key Steps

Six key steps to systematically review the literature are outlined in Table 1 and discussed here.

Systematic Review Steps

1. Formulate the Question and Refine the Topic

When preparing a topic to conduct a systematic review, it is important to ask at the outset, “What exactly am I looking for?” Hopefully it seems like an obvious step, but explicitly writing a one or two sentence statement of the topic before you begin to search is often overlooked. It is important for several reasons; in particular because, although we usually think we know what we are searching for, in truth our mental image of a topic is often quite fuzzy. The act of writing something concise and intelligible to a reader, even if you are the only one who will read it, clarifies your thoughts and can inspire you to ask key questions. In addition, in subsequent steps of the review process, when you begin to develop a strategy for searching the literature, your topic statement is the ready raw material from which you can extract the key concepts and terminology for your strategies. The medical and related health literature is massive, so the more precise and specific your understanding of your information need, the better your results will be when you search.

2. Search, Retrieve, and Select Relevant Articles

The retrieval tools chosen to search the literature should be determined by the purpose of the search. Questions to ask include: For what and by whom will the information be used? A topical expert or a novice? Am I looking for a simple fact? A comprehensive overview on the topic? Exploration of a new topic? A systematic review? For the purpose of a systematic review of journal research in the area of health care, PubMed or Medline is the most appropriate retrieval tool to start with, however other databases may be useful ( Table 2 ). In particular, Google Scholar allows one to search the same set of articles as PubMed/MEDLINE, in addition to some from other disciplines, but it lacks a number of key advanced search features that a skilled searcher can exploit in PubMed/MEDLINE.

Examples of Electronic Bibliographic Databases Specific to Health Care

Note: These databases may be available through university or hospital library systems.

An effective way to search the literature is to break the topic into different “building blocks.” The building blocks approach is the most systematic and works the best in periodical databases such as PubMed/MEDLINE. The “blocks” in a “building blocks” strategy consist of the key concepts in the search topic. For example, let’s say we are interested in researching about mobile phone-based interventions for monitoring of patient status or disease management. We could break the topic into the following concepts or blocks: 1. Mobile phones, 2. patient monitoring, and 3. Disease management. Gather synonyms and related terms to represent each concept and match to available subject headings in databases that offer them. Organize the resulting concepts into individual queries. Run the queries and examine your results to find relevant items and suggest query modifications to improve your results. Revise and re-run your strategy based on your observations. Repeat this process until you are satisfied or further modifications produce no improvements. For example in Medline, these terms would be used in this search and combined as follows: cellular phone AND (ambulatory monitoring OR disease management), where each of the key word phrases is an official subject heading in the MEDLINE vocabulary. Keep detailed notes on the literature search, as it will need to be reported in the methods section of the systematic review paper. Careful noting of search strategies also allows you to revisit a topic in the future and confidently replicate the same results, with the addition of those subsequently published on your topic.

3. Assess Quality

There is no consensus on the best way to assess study quality. Many quality assessment tools include issues such as: appropriateness of study design to the research objective, risk of bias, generalizability, statistical issues, quality of the intervention, and quality of reporting. Reporting guidelines for most literature types are available at the EQUATOR Network website ( http://www.equator-network.org/ ). These guidelines are a useful starting point; however they should not be used for assessing study quality.

4. Extract Data and Information

Extract information from each eligible article into a standardized format to permit the findings to be summarized. This will involve building one or more tables. When making tables each row should represent an article and each column a variable. Not all of the information that is extracted into the tables will end up in the paper. All of the information that is extracted from the eligible articles will help you obtain an overview of the topic, however you will want to reserve the use of tables in the literature review paper for the more complex information. All tables should be introduced and discussed in the narrative of the literature review. An example of an evidence summary table is presented in Table 3 .

Example of an evidence summary table

Notes: BP = blood pressure, HbA1c = Hemoglobin A1c, Hypo = hypoglycemic, I = Internet, NS = not significant, PDA = personal digital assistant, QOL = quality of life, SMBG = self-monitored blood glucose, SMS = short message service, V = voice

5. Analyze and Synthesize Data and information

The findings from individual studies are analyzed and synthesized so that the overall effectiveness of the intervention can be determined. It should also be observed at this time if the effect of an intervention is comparable in different studies, participants, and settings.

6. Write the Systematic Review

The PRISMA 12 and ENTREQ 13 checklists can be useful resources when writing a systematic review. These uniform reporting tools focus on how to write coherent and comprehensive reviews that facilitate readers and reviewers in evaluating the relative strengths and weaknesses. A systematic literature review has the same structure as an original research article:

TITLE : The systematic review title should indicate the content. The title should reflect the research question, however it should be a statement and not a question. The research question and the title should have similar key words.

STRUCTURED ABSTRACT: The structured abstract recaps the background, methods, results and conclusion in usually 250 words or less.

INTRODUCTION: The introduction summarizes the topic or problem and specifies the practical significance for the systematic review. The first paragraph or two of the paper should capture the attention of the reader. It might be dramatic, statistical, or descriptive, but above all, it should be interesting and very relevant to the research question. The topic or problem is linked with earlier research through previous attempts to solve the problem. Gaps in the literature regarding research and practice should also be noted. The final sentence of the introduction should clearly state the purpose of the systematic review.

METHODS: The methods provide a specification of the study protocol with enough information so that others can reproduce the results. It is important to include information on the:

• Eligibility criteria for studies: Who are the patients or subjects? What are the study characteristics, interventions, and outcomes? Were there language restrictions?
• Literature search: What databases were searched? Which key search terms were used? Which years were searched?
• Study selection: What was the study selection method? Was the title screened first, followed by the abstract, and finally the full text of the article?
• Data extraction: What data and information will be extracted from the articles?
• Data analysis: What are the statistical methods for handling any quantitative data?

RESULTS: The results should also be well-organized. One way to approach the results is to include information on the:

• Search results: What are the numbers of articles identified, excluded, and ultimately eligible?
• Study characteristics: What are the type and number of subjects? What are the methodological features of the studies?
• Study quality score: What is the overall quality of included studies? Does the quality of the included studies affect the outcome of the results?
• Results of the study: What are the overall results and outcomes? Could the literature be divided into themes or categories?

DISCUSSION: The discussion begins with a nonnumeric summary of the results. Next, gaps in the literature as well as limitations of the included articles are discussed with respect to the impact that they have on the reliability of the results. The final paragraph provides conclusions as well as implications for future research and current practice. For example, questions for future research on this topic are revealed, as well as whether or not practice should change as a result of the review.

REFERENCES: A complete bibliographical list of all journal articles, reports, books, and other media referred to in the systematic review should be included at the end of the paper. Referencing software can facilitate the compilation of citations and is useful in terms of ensuring the reference list is accurate and complete.

The following resources may be helpful when writing a systematic review:

CEBM: Centre for Evidence-based Medicine. Dedicated to the practice, teaching and dissemination of high quality evidence based medicine to improve health care Available at: http://www.cebm.net/ .

CITING MEDICINE: The National Library of Medicine Style Guide for Authors, Editors, and Publishers. This resource provides guidance in compiling, revising, formatting, and setting reference standards. Available at http://www.ncbi.nlm.nih.gov/books/NBK7265/ .

EQUATOR NETWORK: Enhancing the QUAlity and Transparency Of health Research. The EQUATOR Network promotes the transparent and accurate reporting of research studies. Available at: http://www.equator-network.org/ .

ICMJE RECOMMENDATIONS: International Committee of Medical Journal Editors Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals. The ICJME recommendations are followed by a large number of journals. Available at: http://www.icmje.org/about-icmje/faqs/icmje-recommendations/ .

PRISMA STATEMENT: Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Authors can utilize the PRISMA Statement checklist to improve the reporting of systematic reviews and meta-analyses. Available at: http://prisma-statement.org .

THE COCHRANE COLLABORATION: A reliable source for making evidence generated through research useful for informing decisions about health. Available at: http://www.cochrane.org/ .

Examples of Systematic Reviews To Link Research and Quality Improvement

Over the past 17 years more than 300 learners, including physicians, nurses, and health administrators have completed a course as part of a Master of Health Administration or a Master of Science in Health Informatics degree at the University of Missouri. An objective of the course is to educate health informatics and health administration professionals about how to utilize a systematic, scientific, and evidence-based approach to literature searching, appraisal, and synthesis. Learners in the course conduct a systematic review of the literature on a health care topic of their choosing that could suggest quality improvement in their organization. Students select topics that make sense in terms of their core educational competencies and are related to their work. The categories of topics include public health, leadership, information management, health information technology, electronic medical records, telehealth, patient/clinician safety, treatment/screening evaluation cost/finance, human resources, planning and marketing, supply chain, education/training, policies and regulations, access, and satisfaction. Some learners have published their systematic literature reviews 14 – 15 . Qualitative comments from the students indicate that the course is well received and the skills learned in the course are applicable to a variety of health care settings.

Undertaking a literature review includes identification of a topic of interest, searching and retrieving the appropriate literature, assessing quality, extracting data and information, analyzing and synthesizing the findings, and writing a report. A structured step-by-step approach facilitates the development of a complete and informed literature review.

Suzanne Austin Boren, PhD, MHA, (above) is Associate Professor and Director of Academic Programs, and David Moxley, MLIS, is Clinical Instructor and Associate Director of Executive Programs. Both are in the Department of Health Management and Informatics at the University of Missouri School of Medicine.

Contact: ude.iruossim.htlaeh@snerob

None reported.

• Open access
• Published: 15 April 2024

A logic framework for addressing medical racism in academic medicine: an analysis of qualitative data

• Pamela Roach 1 ,
• Shannon M. Ruzycki 2 , 3 ,
• Kirstie C. Lithgow 2 ,
• Chanda R. McFadden 4 ,
• Adrian Chikwanha 5 ,
• Jayna Holroyd-Leduc 2 , 3 &
• Cheryl Barnabe 2 , 3  

BMC Medical Ethics volume  25 , Article number:  45 ( 2024 ) Cite this article

Metrics details

Despite decades of anti-racism and equity, diversity, and inclusion (EDI) interventions in academic medicine, medical racism continues to harm patients and healthcare providers. We sought to deeply explore experiences and beliefs about medical racism among academic clinicians to understand the drivers of persistent medical racism and to inform intervention design.

We interviewed academically-affiliated clinicians with any racial identity from the Departments of Family Medicine, Cardiac Sciences, Emergency Medicine, and Medicine to understand their experiences and perceptions of medical racism. We performed thematic content analysis of semi-structured interview data to understand the barriers and facilitators of ongoing medical racism. Based on participant narratives, we developed a logic framework that demonstrates the necessary steps in the process of addressing racism using if/then logic. This framework was then applied to all narratives and the barriers to addressing medical racism were aligned with each step in the logic framework. Proposed interventions, as suggested by participants or study team members and/or identified in the literature, were matched to these identified barriers to addressing racism.

Participant narratives of their experiences of medical racism demonstrated multiple barriers to addressing racism, such as a perceived lack of empathy from white colleagues. Few potential facilitators to addressing racism were also identified, including shared language to understand racism. The logic framework suggested that addressing racism requires individuals to understand, recognize, name, and confront medical racism.

Conclusions

Organizations can use this logic framework to understand their local context and select targeted anti-racism or EDI interventions. Theory-informed approaches to medical racism may be more effective than interventions that do not address local barriers or facilitators for persistent medical racism.

Peer Review reports

Racism that disadvantages patients and physicians has been well-documented in peer reviewed literature [ 1 , 2 ], government reports [ 3 , 4 ], and the media [ 5 , 6 , 7 ], in Canada [ 8 ], the United States [ 9 ], and abroad [ 10 ]. While anti-racism may seem to have recently emerged in commentaries and in institutional statements [ 11 ], regular calls [ 3 , 4 , 12 ] for physicians to address racism have been made since at least the early 1990s [ 13 ]. Despite this, racism in the medical field has persisted and continues to be misunderstood [ 6 ] or denied [ 14 ], causing harm to physicians [ 15 , 16 ] and patients [ 8 , 17 ].

A cross-sectional survey of physicians in Alberta to explore racism found that Black, Indigenous, and People of Colour (BIPOC) physicians experience a higher prevalence of racism in the workplace than their white peers [ 18 ]. Analysis of text responses in this survey and others [ 15 , 19 ] provide some understanding of the ways that racism manifests in healthcare, its impact on physicians and patients, and proposes possible interventions to address racism; [ 20 , 21 , 22 ] however, qualitative analysis of interview data that deeply explore experiences and beliefs about racism in medicine are less common [ 23 ]. Further, there is not a unifying, multi-level framework to understand drivers of persistent racism in the medical workplace to inform intervention design. The aim of this current study was to explore physician experiences and perceptions of racism in a Canadian university using semi-structured interviews to inform a model of drivers of persistent racism.

Terminology

Race is a social construct without biologic meaning that is used to categorize people into groups based on their appearance, which are then assigned societal value [ 24 ]. Racial discrimination is disadvantaging a person based on their perceived race, and racism is racial discrimination plus use of power to alter outcomes for a group of people [ 24 ]. White people may experience racial discrimination but not racism, due to their privilege in society [ 24 , 25 ].

In this study, we grouped participant racial identities into white or Black or Indigenous, Asian, and People of Colour (POC) to avoid potential identification of participants from distinct categories. This categorization is meant to differentiate participants who can experience racism (BIPOC) and those who cannot (white); however, these categories are heterogenous and arbitrary. Many groups feel that the term BIPOC enforces hierarchies among people of colour [ 26 ]. We use this term in this manuscript after discussion with study team members with lived experience of racism and colonization, despite these limitations.

Alberta has a single universal healthcare system serving 4.4 million people. There are approximately 11,000 practicing physicians of which 59% are male and 41% are female [ 27 ]. Survey data suggests that less than 3% of practicing physicians in Alberta are gender diverse, transgender, non-binary gender, or Two-Spirit [ 28 ]. Based on survey and census data, an estimated 3–5% of Alberta physicians are Black, 1–3% are Indigenous, 1–3% are Latinx/Hispanic, 5% are Middle Eastern, 10% are South Asian, 7% are East Asian, and 50–70% are white [ 28 ]. Explicit and implicit anti-Black [ 6 ] and anti-Indigenous [ 29 ] interpersonal racism have been documented in Alberta [ 30 ], and this racism results in differential health care delivery for racialized groups [ 1 , 31 ].

This qualitative interview study was approved by the University of Calgary Conjoint Health Research Ethics Board (REB20-1688) and is reported according to the Consolidated criteria for Reporting Qualitative Research (COREQ) guidelines [ 32 ].

Participants

All clinical members (physicians, residents, and nurse practitioners) in the Departments of Medicine ( n  = 420), Family Medicine (academic members only; n  = 40), Cardiac Sciences ( n  = 125), and Emergency Medicine ( n  = 220) in the Cumming School of Medicine, University of Calgary ( n  = 774) were invited to be interviewed about racism in the workplace via a single e-mail from department leadership. These departments were selected because each has an EDI (equity, diversity, and inclusion) committee that can act on the results of this study to implement solutions. All eligible participants were interviewed, without restriction or purposeful sampling by race, with an ethical imperative that all interested participants be offered the opportunity to take part. Further, inclusion of perspectives from racialized and white participants was necessary to address the study objective of understanding experiences and perceptions of medical racism. A single invitation was sent to reduce the burden of e-mails and tasks during the COVID-19 pandemic. Saturation was assessed by inductive thematic saturation, which considers the appearance of new codes or themes rather than the development of existing themes [ 33 ]. Participation was voluntary and compensated with a $50 gift card. All participants provided informed consent, including consent for use of quotes in knowledge dissemination materials.

The interview guide was developed based on the study questions and a review of the literature (Appendix 1 ). Because the aim of this project was to explore physician’s experiences of racism in medicine broadly, the interview guide was to allow participants to guide the interview based on their motivations and priorities. The proposed interview guide was circulated to various university EDI committees for feedback prior to use; it is possible that study participants may have provided input into the developed interview guide. Semi-structured interviews were conducted virtually between April and August 2021 due to local COVID-19 pandemic protocols. Each interview was audio-recorded and transcribed verbatim. Interviewers de-identified transcripts prior to analysis. Participants reviewed their transcripts to suggest edits at their own discretion.

Thematic content analysis [ 34 ] was guided by constructivism, which allows the existence of multiple truths and realities [ 35 ], and performed in NVivo (version 12.3.0, QSR International, Inc., Doncaster, Australia). Initial codes were developed deductively using Dr Camara Jones’ Levels of Racism framework [ 36 ], which organizes racism to three levels: institutional, interpersonal, and internalized. Additional codes were generated inductively through close reading of all transcripts by S.M.R. and C.R.M. Coding was completed independently, in parallel, by S.M.R. and C.R.M. with three transcripts to generate a codebook. The codebook was presented to the entire study team with exemplar quotations to assess validity. The final codebook was then applied to all transcripts (Appendix 2 ). Each transcript was independently analyzed by two study team members with training in qualitative data analysis (S.M.R. and K.C.L. or C.R.M.) and disagreements were reconciled through discussion with the wider study team.

Themes were developed by examining the most prevalent codes for relationships, patterns, commonalities, and differences between participants. After the initial analysis, it was clear that most participant descriptions of an experience of racism had repetitive, ordered elements; a description, an internal reaction, a rationalization, and an external reaction. We therefore organized each narrative about an experience of racism into ordered components to create a logic framework for addressing racism. Logic frameworks are often used to define the purpose and activities of a program by organizing the steps required to achieve the overall project goal [ 37 ]. In our logic framework, the goal was addressing racism in the medical workplace, where ‘addressing’ could mean any personal or organizational intervention to mitigate racism. We then attempted to identify the barrier or facilitator of addressing racism for each narrative by asking “What allowed (or prevented) the participant (or institution) from addressing racism in this experience?”. Each narrative was re-examined in this model and barriers or facilitators at each step were tabulated and consolidated into major categories (Appendix 3 ).

To hypothesize solutions related to each barrier or facilitator, we searched peer-reviewed literature and consulted with colleagues with expertise in EDI. Consultation with experts was solicited by e-mail and through formal discussion during EDI committee meetings in the participating departments.

Reflexivity

Participants were able to select from four trained interviewers (C.R.M., P.R., A.N.C., and S.M.R.), who are diverse in racial identity, gender, profession, and department affiliation. C.R.M. is a white cisgender woman social worker and P.R. is a Métis woman and primary researcher. A.N.C. is a Black man physician. S.M.R. is a white cisgender woman physician. C.R.M., S.M.R., and K.C.L. participated in data analysis. K.C.L. is a white cisgender woman physician. The remaining members of the study team, who provided interim feedback and validation of the study design, data collection and data analysis, also included Métis (C.B) and white (J.H.L.) cisgender women physicians.

This study was funded internally by the Cumming School of Medicine’s Department of Medicine Vice Chair for Indigenous Health, held by one of the study authors (C.B.).

Nineteen interviews (17–90 min) were completed, with respondents representing all participating departments (2.5% participation rate). Respondents were diverse in race and gender identity (Table  1 ). Saturation was reached in creation of the logic framework after 12–15 interviews, as no additional codes or themes were developed after this point. Experiences of or witnessed medical racism were shared by all but one (white) participant. Participant reactions to explicit interpersonal racism varied; while some participants felt reassured knowing that “there was a reason for his (behaviour), it’s not a rational reason, but at least there seems to be an explanation” (BIPOC Participant (BP)1), others felt that “every time it happens, it’s a bit like a slap in the face” (BP7). Many were hesitant to attribute these experiences to racism. Instead, they offered other potential explanations, including “ignorance” (BP4), “genuine surprise” (BP2), “curiosity” (BP16), and “laziness” (BP3).

Addressing racism by addressing barriers and leveraging facilitators: an anti-racism logic framework

The logic framework included understanding, recognizing, naming, and confronting racism as processes required to address racism (Table  2 ; Fig.  1 ). Participant narratives illustrated how each step in this model interacted to prevent addressing racism; for example, if participants did not understand racism, they were unable to recognize racism when it occurred, and participants who did not name an experience as racism were unable to confront racism. This framework allowed us to identify barriers to addressing racism that could be targeted by interventions. Our analysis is presented here in detail.

Logic framework derived from qualitative analysis of interview data. There is a cascading sequential process to addressing racism requiring understanding, recognizing, naming and confronting racism

Understanding racism

Most participants struggled to conceptualize racism. Participants were unsure whether malintent rather than “ignorance or laziness” (BP7) was required. Some participants described a shift in their understanding of intent versus impact throughout their careers and as societal conversations around racism progressed, emphasizing learning about racism as a facilitator for defining racism. Further, most participants did not have a conceptual understanding of racism as being the combination of racial bias and power differential resulting in disadvantages. For example, when asked about experiences of racism, one participant shared that a food service worker told them that a meal had pork in it, and described this as “discrimination, but they’re actually trying to be helpful… because they’re culturally aware that people who look like me don’t eat meat or bacon sometimes,” (BP17). Nearly all participants provided examples of representation as evidence for a lack of racism.

Recognizing racism

Many BIPOC participants wondered “deep down” (BP9, BP16, BP19) if racism had affected their career trajectory. Some felt that, while they could not point to a particular instance, there may be evidence of subtle effects over their entire career: “I’ve never thought of race having an impact in terms of… career advancement opportunities. But recently, when I think back on it, it makes me wonder if there was some degree of that playing a role,” (BP9) and “I’ve not felt that there’s been any attempt to slow me down due to my race (though) sometimes you think that might be the case because it takes you a little longer to get there than others who may be of other racial backgrounds” (BP16). For some, this wondering occupied significant mental space: “You sort of sit back and say ‘Is it because I’m female? Is it because I’m visible minority?’ And you can’t really piece it out. So, I find that is sometimes challenging,” (BP14). Similarly, the invisibility of white privilege was demonstrated by the multiple white participants who assumed that their race “likely allowed some good luck to come my way” though they “don’t recall any specific instances when that happened,” (white participant (WP) 15). Unlike BIPOC participants, no white participant reported distress from the possibility that race had influenced their career trajectories.

BIPOC participants perceived an empathy gap when their white colleagues did not recognize their experiences of racism. Some white participants were aware of the gap between their recognition of workplace racism and their colleagues’ experiences, stating that their view of the workplace as equitable is “a major assumption for me to be making as not part of a racialized minority group,” (WP18). In this way, safe spaces where experiences were shared and validated as racism were a facilitator to counteract the belief that “I thought [racism] happened to just me, I thought it was just like, normal,” (BP8).

Having a shared language to discuss racism was a facilitator for recognizing racism. One participant shared that “I wasn’t familiar with (the) term (microaggressions) until I went to (a) talk. And since that talk, I’ve heard it talked about in all kinds of places…it really resonated with me,” (BP2).

Naming racism

Sociocultural expectations, referring to the professional, social, or cultural norms that police behaviour, were a prominent barrier to naming racism. For example, participants were cautious about “causing a ruckus” (BP2), “rocking the boat” (BP4), “ruffling feathers” (BP12), or being a “hassle” (BP3) when “playing the race card” (BP3, BP9) to describe an experience, worrying that it would “skewer my career” (BP8). Participants felt that “it’s a big deal to call someone a racist, it’s almost one of those taboo terminologies that you save for those people that are mobbing and lynching people,” (BP2). This ‘criminalization’ of race and racism contributes to “an unspoken rule… in healthcare and society” to not discuss race and racism (BP12) and left participants without the language to describe their experiences.

Participants shared that they were raised to “be grateful” for their opportunities, to “work twice as hard as everyone else” (BP1, BP8), and not to “complain” or cause problems (BP2, BP4, BP19), often attributing these values to their parents or culture. With patients, participants felt that they need to be “the better person… the professional” to avoid making patients “uncomfortable” (BP1). Several participants shared that they suppressed their feelings or even memories of racist events as a coping mechanism because “if you think about it, you’d be upset all the time,” (BP1).

Confronting racism

Participants who recognized racism were hesitant to report or confront these experiences because they felt obligated to ‘prove’ their experiences to others. This was especially true for implicit racial bias and systemic discrimination. Participants felt that “it’s a hard case to make, unless you’re very obviously discriminated against and you have a really solid base,” (BP2) and “people within minority groups don’t feel comfortable raising these issues, because then all of a sudden you have to prove (it) to everybody,” (BP9).

Further, participants felt that they risked their reputation by reporting racism, because “people are going to think (I) can’t make it on (my) own merit” (BP2). A shared language to discuss racism facilitated confronting racism; for example, one participant found it helpful to refer to an education session: “I can just say ‘Remember that thing we talked about? You’re doing it right now,’” (WP13). The social risk of confronting racism was overcome when participants witnessed their colleagues as the targets. One participant used the need for trainees “to be in a place where they can feel safe and comfortable learning” (WP6) as justification for dismissing an explicitly racist patient from their practice whereas being the target of racism themselves was not a justification. Some white participants felt cautious speaking up on behalf of their racially marginalized colleagues, “How do you support those people without taking away their agency… but also making sure that they feel safe and they can speak up?” (WP13).

Anti-racism interventions

We identified barriers and facilitators to addressing racism (Fig.  1 ), and then matched these to anti-racism interventions that were suggested by participants directly, developed using the study team members’ expertise, and/or based on peer-reviewed literature. These are summarized in Table  3 and are briefly described here.

Building knowledge to Understand Racism

Organizations can adapt occupational safety strategies [ 46 ] to focus on racism and other EDI concepts. For example, to build collective and organizational knowledge, leaders could reserve time at the beginning of meetings for brief presentations on a single EDI topic [ 41 ].

Developing skills in recognizing racism

Physicians can learn how to recognize medical racism through formal Race and Racism Rounds, modelled after Morbidity and Mortality Rounds, where the adverse clinical outcomes attributable to structural and interpersonal racism are made explicit and discussed [ 42 ]. Similarly, workplace racism can be shared through formal story telling; in these programs, published narratives from physicians who have experienced racism or discrimination [ 43 , 44 , 47 ] are shared and discussed to build empathy and understanding for all physicians. Lastly, facilitated implicit bias training workshops can build skills to recognize racism [ 48 ].

Structural supports for naming racism

Organizations can develop policies that guide decision-making when racism occurs. For example, a directive that establishes the steps that will occur when a patient requests a white physician removes the need for individual physicians to self-advocate. Similarly, creation of safe spaces where physicians who experience racism can network and share their experiences may remove barriers faced by BIPOC physicians when seeking support. Peer support programs can link physicians who experience harassment or discrimination to trained peers with similar lived experiences. All physician leaders must have the skills to appropriately respond to disclosures of racism from their colleagues, to avoid the common experience of being dismissed or unsupported when reporting racism. The number and handling of harassment and discrimination concerns should be regularly reported to organization members to promote accountability [ 45 ].

Taking action to confront racism

As barriers to understanding, recognizing, and naming racism are addressed, organizations must create structures to facilitate confrontation of medical racism. Bystander intervention training can provide skills for physicians to leverage their privilege to safely confront racism in real time [ 49 ]. Organizations must develop evidence-based harassment reporting mechanisms that address known barriers to reporting [ 50 , 51 ] and incorporate remediation-based and restorative justice approaches to harassment.

This study of 19 white and BIPOC faculty members in a single medical school identified that most participants struggled to understand, recognize, name, and confront racism due to individual and structural factors. In a logic framework, these barriers worked together to prevent people and systems from addressing racism in the medical workplace. We matched these barriers to proposed interventions to reduce the barriers or amplify facilitators of addressing racism in medicine. Medical leaders may be able to use these results to identify barriers and facilitators most relevant to their context and implement interventions that target these drivers of ongoing racism.

Previous cross-sectional surveys of Black Canadian physicians estimated a prevalence of workplace racism as 71% [ 15 ], which is in keeping with the prevalence seen among BIPOC physicians in Alberta and across North America [ 19 , 28 ] While many of these studies performed qualitative analysis of survey text responses, analysis of interview data may provide important contextual details on how racism can manifest in medicine [ 34 ]. Several qualitative studies of Black, Native American, and Hispanic academic faculty [ 20 , 23 ] physicians [ 22 , 23 ], and residents [ 21 ] reported the ubiquity of racial microaggressions, the requirement to ‘represent’ ones entire race or ethnicity, and social and professional exclusion, including lack of mentorship. Our study builds on the results of these studies by examining participant reflections on racism in addition to describing their prevalence and impact. This allows us to identify barriers to addressing racism and match interventions to each barrier.

Editorials calling on physicians to address racism in medicine are common [ 52 ] and physicians must not forget that addressing racism in medicine is an ethical obligation of their profession [ 4 , 53 ]. Interventions to address racism in medicine that do not target underlying contributors are unlikely to be successful. This may explain the conflicting data on the effectiveness of interventions such as implicit bias training [ 54 ] or candidate demographic masking [ 55 , 56 ], which are unlikely to be effective in settings where implicit bias is not the primary contributor to racism. Conceptual frameworks can help researchers understand and address complex phenomena [ 57 ] and have been used to examine persistent sexism in medicine [ 58 , 59 ]. Our framework has similarities to the adapted Information-Motivation-Behavioural Skills Model developed by Jindal and colleagues to understand how an anti-racism curriculum could address medical racism among pediatric residents [ 60 ]. This model helps understand factors that impede or promote behavioural interventions by describing the relationship between information, motivation to change, skills needed to change, action planning, and behaviour change. The motivation and action planning domains observed in Jindal’s model were not identified among our data, though the need for information (e.g., understanding) and skills (e.g., recognizing) to address racism were common to both. This finding may be partially due to differences in the study population; in Jindal et al.’s study, 67% of participants were white compared to 5% of our participants. White participants more often mentioned they are motivated to change, given their “sense of responsibility noting their agency to name racism in the moment” [ 60 ] and “one’s own participation in [racist] systems” [ 60 ] than BIPOC participants. Further, in contrast to our exploration of participant experiences of racism, Jindal et al. specifically asked participants about how their anti-racism curricula may lead to changes in clinical practice, which likely prompted more responses that related to the action planning domain [ 60 ].

Our framework provides insights into how institutions can assess where gaps in their current anti-racism work exist along this framework and provides a rationale to select interventions that target these gaps. For example, leaders may use surveys [ 38 ] to determine whether their members have an accurate conceptualization of racism (understanding) before attempting to implement bystander intervention training (confronting) [ 49 ]. Similarly, institutions may benefit from local guidelines to guide physicians in addressing harassment from patients only after its members can recognize racism and its impact on their colleagues.

There are several limitations to this study. The first is possible selection bias, as this was a study examining a sensitive topic, and so our results may represent only the views of those who are most interested or confident about this topic. Social desirability bias may have influenced participant responses due to the presence of an interviewer. Selection and social desirability bias may be why we did not identify explicit interpersonal racism as an important barrier to addressing racism in this study, though explicit racism exists among physicians [ 43 ] and surely plays a role in the persistence of racism in medicine. For this reason, our logic framework may only apply when institutions have addressed explicit racism. Similarly, we did not seek to test the logic model developed from our data and so this is hypothesis-generating only. The logic model should be examined in other settings; it would be important to see if this framework can be used to predict which anti-racism interventions will be most effective. Our results represent the experiences of physicians in different academic departments in a single university and facilitators of racism may be different in settings with different histories or structures of racism and oppression. For example, in settings where anti-racism work is currently being opposed by government and lobby groups [ 39 ] or where anti-Mexican bias is a more predominant form of racism than is typically seen in our setting [ 40 ], there may be different barriers and facilitators.

Overall, this thematic analysis of qualitative data builds on cross-sectional prevalence data and other qualitative explorations of participant experiences to describe how physicians in a single medical school perceive racism in their setting. These results informed a logic model that requires individuals to understand, recognize, name, and confront racism before racism can be effectively addressed by individuals and organizations. Interventions targeted to gaps in this logic model may be better positioned to tackle the challenging and persistence of racism in medicine that harms patients, trainees, and physicians.

Data availability

Select data may be available upon reasonable request from the corresponding author; however, due to the sensitivity of the study data, the full data set will not be provided.

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Acknowledgements

This study was funded internally by the Cumming School of Medicine’s Vice Chair for Indigenous Health, held by one of the study authors (C.B.).

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Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada

Pamela Roach

Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, 1422, T2N 2T9, Canada

Shannon M. Ruzycki, Kirstie C. Lithgow, Jayna Holroyd-Leduc & Cheryl Barnabe

Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada

Shannon M. Ruzycki, Jayna Holroyd-Leduc & Cheryl Barnabe

Department of Allied Health, Alberta Health Services, Calgary, Canada

Chanda R. McFadden

Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada

Adrian Chikwanha

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P.R., S.M.R., K.C.L, C.R.M., A.C., J.H.L., and C.B. contributed to the study conceptualization, study design, revising the manuscript, and approve of the submission of this project. P.R., S.M.R., A.C., and C.R.M. participated in data collection and analysis. K.C.L. participated in data analysis. P.R., A.C., J.H.L., and C.B. reviewed the data analysis. P.R., C.R.M., and S.M.R. drafted the original manuscript. C.B. obtained study funding and provided supervision.

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Correspondence to Shannon M. Ruzycki .

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Approved by the University of Calgary Conjoint Health Research Ethics Board. All participants provided informed consent to participate. All experiments were performed in accordance with relevant guidelines and regulations.

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None of the authors have relevant competing interests to declare.

P.R. and C.B. are Métis women who have lived experience of anti-Indigenous racism in the healthcare system. A.C. is a Black man. S.M.R., K.C.L., C.R.M., and J.H.L. are white women.

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Roach, P., Ruzycki, S.M., Lithgow, K.C. et al. A logic framework for addressing medical racism in academic medicine: an analysis of qualitative data. BMC Med Ethics 25 , 45 (2024). https://doi.org/10.1186/s12910-024-01045-9

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Concerns about eye discomfort appear to rise after solar eclipse

Google searches about “hurt eyes” spiked Monday afternoon, just after many U.S. communities experienced the total solar eclipse. 

The searches suggest some people in the sun’s path were worried they’d glanced at it too long. 

It’s a valid concern, eye experts said. Looking at the sun without protective equipment can harm your vision, and complaints of eye issues have been documented after past eclipse events. However, cases of long-term damage after eclipses aren’t common.

In addition, hurting eyes aren’t the best indicator of a severe problem: Injuries from “solar retinopathy,” when light injures retinas, occur without immediate pain. 

Two main types of injuries are possible from looking at the sun — a burn to the outside of the eye and damage to nerve tissue within. 

“You can get a little bit of a burn to the surface of the eye, or what we call solar keratitis,” said Dr. Daniel Lattin, an ophthalmologist at Nemours Children’s Health in Jacksonville, Florida. “You can get sort of a burn to that cornea, and that’ll cause redness and tearing and those sorts of symptoms. That should resolve on its own, within a day or two, without any sort of permanent damage.”

That type of injury is rare, and it’s more commonly associated with climbers who spend time at high altitudes without proper eye protection, said Dr. Russell Van Gelder, an ophthalmologist at University of Washington Medicine and the director of the Karalis Johnson Retina Center in Seattle.

“It’s pretty hard to get that eclipse gazing; you need a fair amount of exposure,” Van Gelder said. 

Vision symptoms are more likely and worthy of concern. 

“If you have symptoms of a blind spot, wavy lines, floaters or blurry vision, that could be solar retinopathy after this eclipse, and you need to be seen right away,” said Dr. Luxme Hariharan, chief of ophthalmology at Dayton Children’s Hospital in Ohio. 

Hariharan said symptoms of solar retinopathy typically develop in the 24 hours after sun exposure. The condition isn’t associated with pain. 

“It’s not a pain sensation,” Van Gelder said. “The retina is devoid of the sense of pain or temperature. The retina can’t feel when it’s injured.” 

Lattin said there’s no treatment for solar retinopathy, though some patients’ eyes will recover over time.

Limited data suggests prolonged problems aren’t common. Only about 100 patients reported “eclipse-related retinopathy” after the 2017 total solar eclipse, according to a technical report published by the American Astronomical Society . Children and young adults were the most likely to be affected, according to the report, which based its estimates on informal survey data. 

Van Gelder said no national registry keeps track of such injuries. 

After the 2017 eclipse, he said, his clinic treated a half-dozen patients in Seattle who had eye complaints. He treated two of them directly, both of whom experienced partial recoveries. 

“If people are having pain, it’s probably not anything significant,” Van Gelder said. “If they have vision issues, they should be seen.” 

Experts said it doesn’t take long to damage the eyes after you gaze at the sun. 

“It can take as little as one to two seconds where you’re looking at it unprotected if you’re not using the glasses,” Hariharan said. “The problem is when the moon is blocking it in totality and it’s cloudy, you think it’s safe to look at, and people will stare at it for longer.”

Evan Bush is a science reporter for NBC News. He can be reached at [email protected].

Aria Bendix is the breaking health reporter for NBC News Digital.

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Youth Gender Medications Limited in England, Part of Big Shift in Europe

Five European countries have recently restricted hormone treatments for adolescents with gender distress. They have not banned the care, unlike many U.S. states.

By Azeen Ghorayshi

Azeen Ghorayshi reports on transgender health and visited the world’s first youth gender clinic in Amsterdam this fall.

The National Health Service in England started restricting gender treatments for children this month, making it the fifth European country to limit the medications because of a lack of evidence of their benefits and concern about long-term harms.

England’s change resulted from a four-year review released Tuesday evening by Dr. Hilary Cass, an independent pediatrician. “For most young people, a medical pathway will not be the best way to manage their gender-related distress,” the report concluded. In a related editorial published in a medical journal, Dr. Cass said the evidence that youth gender treatments were beneficial was “built on shaky foundations.”

The N.H.S. will no longer offer drugs that block puberty , except for patients enrolled in clinical research. And the report recommended that hormones like testosterone and estrogen, which spur permanent physical changes, be prescribed to minors with “extreme caution.” (The guidelines do not apply to doctors in private practice, who serve a small fraction of the population.)

England’s move is part of a broader shift in northern Europe, where health officials have been concerned by soaring demand for adolescent gender treatments in recent years. Many patients also have mental health conditions that make it difficult to pinpoint the root cause of their distress, known as dysphoria.

In 2020, Finland’s health agency restricted the care by recommending psychotherapy as the primary treatment for adolescents with gender dysphoria. Two years later, Sweden restricted hormone treatments to “exceptional cases.”

In December, regional health authorities in Norway designated youth gender medicine as a “treatment under trial,” meaning hormones will be prescribed only to adolescents in clinical trials. And in Denmark, new guidelines being finalized this year will limit hormone treatments to transgender adolescents who have experienced dysphoria since early childhood.

Several transgender advocacy groups in Europe have condemned the changes , saying that they infringe on civil rights and exacerbate the problems of overstretched health systems. In England, around 5,800 children were on the waiting list for gender services at the end of 2023, according to the N.H.S.

“The waiting list is known to be hell,” said N., a 17-year-old transgender boy in southern England who requested to withhold his full name for privacy. He has been on the waiting list for five years, during which time he was diagnosed with autism and depression. “On top of the trans panic our own government is pushing, we feel forgotten and left behind,” he said.

In the United States, Republican politicians have cited the pullback in Europe to justify laws against youth gender medicine. But the European policies are notably different from the outright bans for adolescents passed in 22 U.S. states, some of which threaten doctors with prison time or investigate parents for child abuse. The European countries will still allow gender treatments for certain adolescents and are requiring new clinical trials to study and better understand their effects.

“We haven’t banned the treatment,” said Dr. Mette Ewers Haahr, a psychiatrist who leads Denmark’s sole youth gender clinic, in Copenhagen. Effective treatments must consider human rights and patient safety, she said. “You have to weigh both.”

In February, the European Academy of Paediatrics acknowledged the concerns about youth gender medicine. “The fundamental question of whether biomedical treatments (including hormone therapy) for gender dysphoria are effective remains contested,” the group wrote. In contrast, the American Academy of Pediatrics last summer reaffirmed its endorsement of the care, stating that hormonal treatments are essential and should be covered by health insurers, while also commissioning a systematic review of evidence.

Europeans pioneered the use of gender treatments for young people. In the 1990s, a clinic in Amsterdam began giving puberty-suppressing drugs to adolescents who had felt they were a different gender since early childhood.

The Dutch doctors reasoned that puberty blockers could give young patients with gender dysphoria time to explore their identity and decide whether to proceed with hormones to ultimately transition. For patients facing male puberty, the drugs would stave off the physical changes — such as a deeper voice and facial hair — that could make it more difficult for them to live as women in adulthood. The Dutch team’s research, which was first published in 2011 and tracked a carefully selected group of 70 adolescents, found that puberty blockers, in conjunction with therapy, improved psychological functioning.

That study was hugely influential, inspiring clinics around the world to follow the Dutch protocol. Referrals to these clinics began to surge around 2014, though the numbers remain small. At Sweden’s clinic, for example, referrals grew to 350 adolescents in 2022 from around 50 in 2014. In England, those numbers grew to 3,600 referrals in 2022 from 470 in 2014.

Clinics worldwide reported that the increase was largely driven by patients raised as girls. And unlike the participants in the original Dutch study, many of the new patients did not experience gender distress until puberty and had other mental health conditions, including depression and autism.

Given these changes, some clinicians are questioning the relevance of the original Dutch findings for today’s patients.

“The whole world is giving the treatment, to thousands, tens of thousands of young people, based on one study,” said Dr. Riittakerttu Kaltiala, a psychiatrist who has led the youth gender program in Finland since 2011 and has become a vocal critic of the care.

Dr. Kaltiala’s own research found that about 80 percent of patients at the Finnish clinic were born female and began experiencing gender distress later in adolescence. Many patients also had psychological issues and were not helped by hormonal treatments, she found. In 2020, Finland severely limited use of the drugs.

Around the same time, the Swedish government commissioned a rigorous research review that found “insufficient” evidence for hormone therapies for youth. In 2022, Sweden recommended hormones only for “exceptional cases,” citing in part the uncertainty around how many young people may choose to stop or reverse their medical transitions down the line, known as detransitioning.

Even the original Dutch clinic is facing pressure to limit patients receiving the care. In December, a public documentary series in the Netherlands questioned the basis of the treatments. And in February, months after a far-right political party swept an election in a country long known as socially liberal , the Dutch Parliament passed a resolution to conduct research comparing the current Dutch approach with that of other European countries.

“I would have liked that the Netherlands was an island,” said Dr. Annelou de Vries, a psychiatrist who led the original Dutch research and still heads the Amsterdam clinic. “But of course, we are not — we are also part of the global world. So in a way, if everybody is starting to be concerned, of course, these concerns come also to our country.”

In England, brewing concerns about the surge of new patients reached a boiling point in 2018, when 10 clinicians at the N.H.S.’s sole youth gender clinic, known as the Tavistock Gender Identity Development Service, formally complained that they felt pressure to quickly approve children, including those with serious mental health problems, for puberty blockers.

In 2021, Tavistock clinicians published a study of 44 children who took puberty blockers that showed a different result from the Dutch: The patients given the drugs, on average, saw no impact on psychological function.

Although the drugs did not lessen thoughts of self-harm or the severity of dysphoria, the adolescents were “resoundingly thrilled to be on the blocker,” Dr. Polly Carmichael, the head of the clinic, said at a 2016 conference . And 43 of the 44 study participants later chose to start testosterone or estrogen, raising questions about whether the drug was serving its intended purpose of giving adolescents time to consider whether a medical transition was right for them.

In 2020, the N.H.S. commissioned Dr. Cass to carry out an independent review of the treatments. She commissioned scientific reviews and considered international guidelines of the care. She also met with young people and their families, trans adults, people who had detransitioned, advocacy groups and clinicians.

The review concluded that the N.H.S.’s standard of care was inadequate, with long waiting lists for access to drug treatments and few routes to address the mental health concerns that may be contributing to gender distress. The N.H.S. shuttered the Tavistock center last month and opened two new youth gender clinics, which Dr. Cass said should have a “holistic” approach, with more support for those with autism, depression and eating disorders, as well as psychotherapy to help adolescents explore their identities.

“Children and young people have just been really poorly served,” Dr. Cass said in an interview with the editor of The British Medical Journal, released Tuesday. She added, “I can’t think of another area of pediatric care where we give young people potentially irreversible treatments and have no idea what happens to them in adulthood.”

The changes enacted by the N.H.S. this month are “an acknowledgment that our concerns were, in fact, valid,” said Anna Hutchinson, a clinical psychologist in London who was one of the Tavistock staff members who raised concerns in 2018. “It’s reassuring that we’re going to return to a more robust, evidence-based pathway for decisions relating to these children.”

Some critics said that Europe, like the United States, had also been influenced by a growing backlash against transgender people.

In Britain, for example, a yearslong fight over a proposed law that would have made it easier for transgender people to change the gender on their identification documents galvanized a political movement to try to exclude transgender women from women’s sports, prisons and domestic violence shelters.

“The intention with the Cass review is to be neutral, but I think that neutral has maybe moved,” said Laurence Webb, a representative from Mermaids, a trans youth advocacy organization in Britain. “Extremist views have become much more normalized.”

Other countries have seen more overt attacks on transgender rights and health care. In 2020, Hungary’s Parliament passed a law banning gender identity changes on legal documents. Last year, Russia banned legal gender changes as well as gender-related medical care, with one lawmaker describing gender surgeries as the “path to the degeneration of the nation.”

In France this year, a group of conservative legislators introduced a bill to ban doctors from prescribing puberty blockers and hormones, with punishments of two years’ imprisonment and a fine of 30,000 euros, or about $32,600. And on Monday, the Vatican condemned gender transitions as threats to human dignity.

Azeen Ghorayshi covers the intersection of sex, gender and science for The Times. More about Azeen Ghorayshi

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How can I plan what to eat or drink when I have diabetes?

How can physical activity help manage my diabetes, what can i do to reach or maintain a healthy weight, should i quit smoking, how can i take care of my mental health, clinical trials for healthy living with diabetes.

Healthy living is a way to manage diabetes . To have a healthy lifestyle, take steps now to plan healthy meals and snacks, do physical activities, get enough sleep, and quit smoking or using tobacco products.

Healthy living may help keep your body’s blood pressure , cholesterol , and blood glucose level, also called blood sugar level, in the range your primary health care professional recommends. Your primary health care professional may be a doctor, a physician assistant, or a nurse practitioner. Healthy living may also help prevent or delay health problems  from diabetes that can affect your heart, kidneys, eyes, brain, and other parts of your body.

Making lifestyle changes can be hard, but starting with small changes and building from there may benefit your health. You may want to get help from family, loved ones, friends, and other trusted people in your community. You can also get information from your health care professionals.

What you choose to eat, how much you eat, and when you eat are parts of a meal plan. Having healthy foods and drinks can help keep your blood glucose, blood pressure, and cholesterol levels in the ranges your health care professional recommends. If you have overweight or obesity, a healthy meal plan—along with regular physical activity, getting enough sleep, and other healthy behaviors—may help you reach and maintain a healthy weight. In some cases, health care professionals may also recommend diabetes medicines that may help you lose weight, or weight-loss surgery, also called metabolic and bariatric surgery.

Choose healthy foods and drinks

There is no right or wrong way to choose healthy foods and drinks that may help manage your diabetes. Healthy meal plans for people who have diabetes may include

• dairy or plant-based dairy products
• nonstarchy vegetables
• protein foods
• whole grains

Try to choose foods that include nutrients such as vitamins, calcium , fiber , and healthy fats . Also try to choose drinks with little or no added sugar , such as tap or bottled water, low-fat or non-fat milk, and unsweetened tea, coffee, or sparkling water.

Try to plan meals and snacks that have fewer

• foods high in saturated fat
• foods high in sodium, a mineral found in salt
• sugary foods , such as cookies and cakes, and sweet drinks, such as soda, juice, flavored coffee, and sports drinks

Your body turns carbohydrates , or carbs, from food into glucose, which can raise your blood glucose level. Some fruits, beans, and starchy vegetables—such as potatoes and corn—have more carbs than other foods. Keep carbs in mind when planning your meals.

You should also limit how much alcohol you drink. If you take insulin  or certain diabetes medicines , drinking alcohol can make your blood glucose level drop too low, which is called hypoglycemia . If you do drink alcohol, be sure to eat food when you drink and remember to check your blood glucose level after drinking. Talk with your health care team about your alcohol-drinking habits.

Find the best times to eat or drink

Talk with your health care professional or health care team about when you should eat or drink. The best time to have meals and snacks may depend on

• what medicines you take for diabetes
• what your level of physical activity or your work schedule is
• whether you have other health conditions or diseases

Ask your health care team if you should eat before, during, or after physical activity. Some diabetes medicines, such as sulfonylureas  or insulin, may make your blood glucose level drop too low during exercise or if you skip or delay a meal.

Plan how much to eat or drink

You may worry that having diabetes means giving up foods and drinks you enjoy. The good news is you can still have your favorite foods and drinks, but you might need to have them in smaller portions  or enjoy them less often.

For people who have diabetes, carb counting and the plate method are two common ways to plan how much to eat or drink. Talk with your health care professional or health care team to find a method that works for you.

Carb counting

Carbohydrate counting , or carb counting, means planning and keeping track of the amount of carbs you eat and drink in each meal or snack. Not all people with diabetes need to count carbs. However, if you take insulin, counting carbs can help you know how much insulin to take.

Plate method

The plate method helps you control portion sizes  without counting and measuring. This method divides a 9-inch plate into the following three sections to help you choose the types and amounts of foods to eat for each meal.

• Nonstarchy vegetables—such as leafy greens, peppers, carrots, or green beans—should make up half of your plate.
• Carb foods that are high in fiber—such as brown rice, whole grains, beans, or fruits—should make up one-quarter of your plate.
• Protein foods—such as lean meats, fish, dairy, or tofu or other soy products—should make up one quarter of your plate.

If you are not taking insulin, you may not need to count carbs when using the plate method.

Work with your health care team to create a meal plan that works for you. You may want to have a diabetes educator  or a registered dietitian  on your team. A registered dietitian can provide medical nutrition therapy , which includes counseling to help you create and follow a meal plan. Your health care team may be able to recommend other resources, such as a healthy lifestyle coach, to help you with making changes. Ask your health care team or your insurance company if your benefits include medical nutrition therapy or other diabetes care resources.

Talk with your health care professional before taking dietary supplements

There is no clear proof that specific foods, herbs, spices, or dietary supplements —such as vitamins or minerals—can help manage diabetes. Your health care professional may ask you to take vitamins or minerals if you can’t get enough from foods. Talk with your health care professional before you take any supplements, because some may cause side effects or affect how well your diabetes medicines work.

Research shows that regular physical activity helps people manage their diabetes and stay healthy. Benefits of physical activity may include

• lower blood glucose, blood pressure, and cholesterol levels
• better heart health
• healthier weight
• better mood and sleep
• better balance and memory

Talk with your health care professional before starting a new physical activity or changing how much physical activity you do. They may suggest types of activities based on your ability, schedule, meal plan, interests, and diabetes medicines. Your health care professional may also tell you the best times of day to be active or what to do if your blood glucose level goes out of the range recommended for you.

Do different types of physical activity

People with diabetes can be active, even if they take insulin or use technology such as insulin pumps .

Try to do different kinds of activities . While being more active may have more health benefits, any physical activity is better than none. Start slowly with activities you enjoy. You may be able to change your level of effort and try other activities over time. Having a friend or family member join you may help you stick to your routine.

The physical activities you do may need to be different if you are age 65 or older , are pregnant , or have a disability or health condition . Physical activities may also need to be different for children and teens . Ask your health care professional or health care team about activities that are safe for you.

Aerobic activities

Aerobic activities make you breathe harder and make your heart beat faster. You can try walking, dancing, wheelchair rolling, or swimming. Most adults should try to get at least 150 minutes of moderate-intensity physical activity each week. Aim to do 30 minutes a day on most days of the week. You don’t have to do all 30 minutes at one time. You can break up physical activity into small amounts during your day and still get the benefit. 1

Strength training or resistance training

Strength training or resistance training may make your muscles and bones stronger. You can try lifting weights or doing other exercises such as wall pushups or arm raises. Try to do this kind of training two times a week. 1

Balance and stretching activities

Balance and stretching activities may help you move better and have stronger muscles and bones. You may want to try standing on one leg or stretching your legs when sitting on the floor. Try to do these kinds of activities two or three times a week. 1

Some activities that need balance may be unsafe for people with nerve damage or vision problems caused by diabetes. Ask your health care professional or health care team about activities that are safe for you.

Stay safe during physical activity

Staying safe during physical activity is important. Here are some tips to keep in mind.

Drink liquids

Drinking liquids helps prevent dehydration , or the loss of too much water in your body. Drinking water is a way to stay hydrated. Sports drinks often have a lot of sugar and calories , and you don’t need them for most moderate physical activities.

Avoid low blood glucose

Check your blood glucose level before, during, and right after physical activity. Physical activity often lowers the level of glucose in your blood. Low blood glucose levels may last for hours or days after physical activity. You are most likely to have low blood glucose if you take insulin or some other diabetes medicines, such as sulfonylureas.

Ask your health care professional if you should take less insulin or eat carbs before, during, or after physical activity. Low blood glucose can be a serious medical emergency that must be treated right away. Take steps to protect yourself. You can learn how to treat low blood glucose , let other people know what to do if you need help, and use a medical alert bracelet.

Avoid high blood glucose and ketoacidosis

Taking less insulin before physical activity may help prevent low blood glucose, but it may also make you more likely to have high blood glucose. If your body does not have enough insulin, it can’t use glucose as a source of energy and will use fat instead. When your body uses fat for energy, your body makes chemicals called ketones .

High levels of ketones in your blood can lead to a condition called diabetic ketoacidosis (DKA) . DKA is a medical emergency that should be treated right away. DKA is most common in people with type 1 diabetes . Occasionally, DKA may affect people with type 2 diabetes  who have lost their ability to produce insulin. Ask your health care professional how much insulin you should take before physical activity, whether you need to test your urine for ketones, and what level of ketones is dangerous for you.

Take care of your feet

People with diabetes may have problems with their feet because high blood glucose levels can damage blood vessels and nerves. To help prevent foot problems, wear comfortable and supportive shoes and take care of your feet  before, during, and after physical activity.

If you have diabetes, managing your weight  may bring you several health benefits. Ask your health care professional or health care team if you are at a healthy weight  or if you should try to lose weight.

If you are an adult with overweight or obesity, work with your health care team to create a weight-loss plan. Losing 5% to 7% of your current weight may help you prevent or improve some health problems  and manage your blood glucose, cholesterol, and blood pressure levels. 2 If you are worried about your child’s weight  and they have diabetes, talk with their health care professional before your child starts a new weight-loss plan.

You may be able to reach and maintain a healthy weight by

• following a healthy meal plan
• consuming fewer calories
• being physically active
• getting 7 to 8 hours of sleep each night 3

If you have type 2 diabetes, your health care professional may recommend diabetes medicines that may help you lose weight.

Online tools such as the Body Weight Planner  may help you create eating and physical activity plans. You may want to talk with your health care professional about other options for managing your weight, including joining a weight-loss program  that can provide helpful information, support, and behavioral or lifestyle counseling. These options may have a cost, so make sure to check the details of the programs.

Your health care professional may recommend weight-loss surgery  if you aren’t able to reach a healthy weight with meal planning, physical activity, and taking diabetes medicines that help with weight loss.

If you are pregnant , trying to lose weight may not be healthy. However, you should ask your health care professional whether it makes sense to monitor or limit your weight gain during pregnancy.

Both diabetes and smoking —including using tobacco products and e-cigarettes—cause your blood vessels to narrow. Both diabetes and smoking increase your risk of having a heart attack or stroke , nerve damage , kidney disease , eye disease , or amputation . Secondhand smoke can also affect the health of your family or others who live with you.

If you smoke or use other tobacco products, stop. Ask for help . You don’t have to do it alone.

Feeling stressed, sad, or angry can be common for people with diabetes. Managing diabetes or learning to cope with new information about your health can be hard. People with chronic illnesses such as diabetes may develop anxiety or other mental health conditions .

Learn healthy ways to lower your stress , and ask for help from your health care team or a mental health professional. While it may be uncomfortable to talk about your feelings, finding a health care professional whom you trust and want to talk with may help you

• lower your feelings of stress, depression, or anxiety
• manage problems sleeping or remembering things
• see how diabetes affects your family, school, work, or financial situation

Ask your health care team for mental health resources for people with diabetes.

Sleeping too much or too little may raise your blood glucose levels. Your sleep habits may also affect your mental health and vice versa. People with diabetes and overweight or obesity can also have other health conditions that affect sleep, such as sleep apnea , which can raise your blood pressure and risk of heart disease.

NIDDK conducts and supports clinical trials in many diseases and conditions, including diabetes. The trials look to find new ways to prevent, detect, or treat disease and improve quality of life.

What are clinical trials for healthy living with diabetes?

Clinical trials—and other types of clinical studies —are part of medical research and involve people like you. When you volunteer to take part in a clinical study, you help health care professionals and researchers learn more about disease and improve health care for people in the future.

Researchers are studying many aspects of healthy living for people with diabetes, such as

• how changing when you eat may affect body weight and metabolism
• how less access to healthy foods may affect diabetes management, other health problems, and risk of dying
• whether low-carbohydrate meal plans can help lower blood glucose levels
• which diabetes medicines are more likely to help people lose weight

Find out if clinical trials are right for you .

Watch a video of NIDDK Director Dr. Griffin P. Rodgers explaining the importance of participating in clinical trials.

What clinical trials for healthy living with diabetes are looking for participants?

You can view a filtered list of clinical studies on healthy living with diabetes that are federally funded, open, and recruiting at www.ClinicalTrials.gov . You can expand or narrow the list to include clinical studies from industry, universities, and individuals; however, the National Institutes of Health does not review these studies and cannot ensure they are safe for you. Always talk with your primary health care professional before you participate in a clinical study.

This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. NIDDK translates and disseminates research findings to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by NIDDK is carefully reviewed by NIDDK scientists and other experts.

NIDDK would like to thank: Elizabeth M. Venditti, Ph.D., University of Pittsburgh School of Medicine.