Jonathan Roos: Let’s hear it for the case report

picture-1To date, more than 56 million papers have been published in the scientific literature. Astonishingly, printing out just the first page of each would create a stack almost 6km high—much higher than the Mont Blanc—Europe’s highest mountain at 4,809 metres. Or in man-made terms—stacking London’s Canary Wharf tower 20 times on top of itself or the Eiffel Tower 15 times.

The journal Nature recently commissioned a review which found that only 1m of these 56 million papers had more than 100 citations. The 10 top cited scientific publications of all time concern new methods—how to measure protein concentration (305,148 citations), how to sequence DNA (213,005) and how to isolate lipids (45,131). Not here the discovery of antibiotics, phacoemulsification for cataract surgery, or the first corneal transplant.

More than a third of our mountainous stack of first pages has never been cited; about another third has been cited less than 10 times. So are most of our efforts at publishing wasted? Time sacrificed that might have been better spent barbecuing with friends? To paraphrase Einstein: not everything of value can be measured and not all that can be measured has value. And nowhere is this more true than in the science, art, and humanity of medicine.

But for young(-ish) doctors embarking on medico-scientific careers it will be an uphill struggle—for the journals that support our specialties are succumbing to the tyranny of impact factors.  The most obvious casualty being the much-maligned, lowly, single case report.

What is a case report? It is a story of one human, and their medical team, struggling in some way against ill health and in relative darkness—hence the novelty factor triggering the need to report it. The case report therefore serves the purpose of providing a little lantern for future sufferers, and helping us to slowly move from ignorance to insight. This is what separates medieval quackery from modern medicine—we share and build on experience which is peer reviewed and then informs others. Eventually a case series or meta-analysis might ensue. It also acts as a calling card—here is a team who have seen this before and who might be contacted for advice. With today’s prolific publishing we take such helpful advice almost for granted. But the old institutions that have taught medicine for centuries remember that it was not always so. Oxford University’s motto prays for this light (Dominus illuminatio mea), Harvard’s is simply Veritas—truth.

Going back two millennia, Hippocrates urged doctors to teach others medicine so that they could pass on their insights, allowing us to build on our colleagues’ experiences and for medicine to prosper for the benefit of us all. We have been on a slow journey, starting from a few case reports and resulting in the medico-industrial powerhouse we enjoy today.

So is the case report a historical curiosity, no longer necessary in the days of the internet and patient support groups?  I don’t think so.

In writing a case report we are reminded of the individuality and uniqueness of our patients—which in turn reminds us to be humble; there is so much we do not know. I recently—at a cost of over £400—published a case of a 44 year old woman who is still alive four years after treatment with stereotactic radiotherapy for a metastatic carcinoma encircling her carotid artery within the cavernous sinus. This had been deemed inoperable and she was for palliative care only. However she sought out further therapy with a uniquely successful result. Case reports remind us that we can never be certain of a prognosis.

Case reports can also be the only means by which to advance learning, for example for very rare diseases. Our understanding of orphan diseases, such as Sandhoff disease, or Aicardi syndrome, have arisen through the painstaking accumulation of case reports in the literature, carefully documenting individual patients to eventually allow the natural history of a disease to be pieced together.

Finally, case reports—though impersonally written and anonymised—offer a human side to medical care, both for patients and doctors. We can tell our patients that yes, someone else has had this condition. Yes, we the medical profession have some experience of dealing with this disease. Or yes, you are unique but we will share your story with others so that your experience can help them. For those suffering iatrogenic harm or from a rare condition such words too can be soothing. You the patient, and we your doctors, are not alone.

Access to this fount of knowledge comes with important responsibilities too: a duty for us to share medical insights—for it may be our patient who holds the clue to a new diagnosis or approach; there is no opt out. There is also an equal duty not to fabricate. Journals increasingly request patient’s permission to tell even their anonymised stories. I do not agree with this approach. If a patient turns to modern medicine it is to avail themselves of other patients’ suffering and experiences. There is a moral duty to not just take, but to volunteer information back too for the greater good. Of course the very best journals—the New England Journal of Medicine & the Lancet for example—recognise the value of single case reports and still publish them.

In the land of the blind, the one-eyed man is king—and so the case report can offer some guidance where there might otherwise be none. So may I urge all editors to throw off the shackles of impact factors—most papers after all are cited incredibly infrequently if at all, and to focus ruthlessly on quality and accuracy and embrace excellent case reports. For they continue to slowly lead us to truth and light.

Jonathan Roos is currently in subspecialty training in oculoplastics & periorbital reconstructive surgery. After embarking on the Cambridge MB PhD programme he became a visiting research fellow at Harvard, Cambridge NIHR Clinical Fellow, and chief resident. 

Competing interests:  None declared.