This case report has spent a long time in review because it has been a challenge to strike a balance in the conclusions between acknowledging the risk of a particular model of health care and how that risk compares with other models. The authors have worked hard to focus the report on the particular case they report, explore the questions it raises about telephone triage systems and what form of evaluation should be undertaken on them. Telephone triage has clear advantages but the authors, with this illustrative case, question the associated risks and how they may be evaluated.

Dean Jenkins
Editor at Large

Death of an infant after contacting a telephone triage call centre: is telephone triage really safe?

The authors of this case report, “Ineffective chronic illness behaviour,” illustrate how difficulties in treatment interactions need analysis beyond the patient’s presumed diagnosis or disorder
– especially when patients’ behaviour during treatment is unusual or unexpected related to the primary symptoms.

The authors describe their patient’s behaviour as “a form of ineffective chronic illness behaviour that has been jointly but inadvertently created by patient and professional. Analyzing the situation from this perspective, another strategy – apart from referral or “pampering and dithering” – is within reach: making a fresh start in the treatment process of the so-called
“difficult” patient.”

“Such an endeavour includes, but is not necessarily limited to: a disentanglement of symptoms and (learned) illness behaviour, an analysis of the dynamics of the treatment alliance, a reconsideration of the given diagnosis and available treatment options, and – preferably – a discussion with the patient about aforementioned issues. In this case, the authors choose to discuss the issues openly with the patient, starting from the concept of the “difficult” patient, who runs the risk to be expelled from every health care system available.”

They then jointly establish a “explanatory theory of patient’s claim on care: an enduring lack of recognition of qualities and vulnerabilities by important others.”

Particularly interesting in this case was the role of a community nurse (and researcher) who assumed “a case-manager role, coordinating efforts to ameliorate social problems (including work and meaningful contacts), to structure access to additional psychiatric care (e.g. crisis intervention, hospitalization), and to be a trusted person in the background.”

The case report describes in lucid detail how these joint efforts between multiple stakeholders have decreased the patient’s symptoms, improved his social functioning, and limited his health care use.

Rakesh Biswas
Deputy Editor

Ineffective chronic illness behaviour in a patient with long-term non-psychotic psychiatric illness

Had a debate at the recent Warwick Medical School Journal Club workshop on case reports.

“This house believes that case reports are a waste of time in the era of evidence-based medicine.”

The  students from medical schools over the UK came up with many of the arguments for and against the motion.

for the motion and against case reports

• case reports are rarities that are of no relevance outside the case
• n=1 is often not of much use as it doesn’t lend itself to statistics

against the motion and for case reports

• first line of evidence especially for new treatments / conditions or harmful drugs
• they provide a trail of evidence especially for rarer conditions
• educational especially for those topic areas that don’t lend themselves to quantitative study

I’ve discussed these arguments before in what shall we do with case reports?

It was a really useful way for setting the scene for discussing what makes a good case report and, in particular, what BMJ Case Reports looks for in submissions. This was the purpose of the workshop and there was a lively discussion and many queries afterwards about certain pictures that might make a good “Images in …” article and a lot of questions about patient consent.

The main interest among the students was that case reports are a good way to learn about academic writing – by responding to criticisms from colleagues, editors and peer reviewers – and a first step in publications. Whilst not wanting to encourage any and all case assignments (which would make for dreary reading) we did explore some suggestions for choosing good cases that they may want to start writing up.

• Present your case at medical meetings and see what discussion (if any) occurs afterwards. This will help identify the key messages and whether they are educational or scientific. If there is no discussion then maybe it isn’t that interesting a case.
• Learn to search the medical literature and find existing case reports, evidence and opinion, already published that are relevant to your case. Even if something has been published before does not necessarily mean a well written, educational reminder linking the often un-cited existing reports together can be a useful publication.

It was a very enjoyable event and well organised by the WMS Journal Club.

Looking forward to taking the BMJ Case Reports roadshow to other medical schools / societies / colleges … but perhaps when the snow has thawed.

Dean Jenkins
Editor at Large