What shall we do with case reports?

Case reports are popular and well-known but they have attracted criticism. They can distract the reader with the unusual. They are often not cited and mainstream journals are reluctant to publish them since they may lower impact factor. Their conclusions are rarely investigated further and may not be relevant outside the novelty of the case.

However, we feel there is great value in a well written case report.

The challenge of medicine is not only in managing the routine and well researched, but in recognising the strange. For example in my experience the majority of cases in an acute medical ward round consist of well documented common conditions. Communication with patients, relatives and staff is the skill that ensures the safe management of these cases and there are plenty of sources of evidence should the correct pathway or protocol be in doubt. It is the minority of cases, that are not what they seem, that present the greatest challenge and risk.

Being able to suspect that a case presentation or set of clinical findings does not fit the usual is a skill. Teaching this skill is difficult. Researching the cases that are exceptions, including the quite rare, is even more difficult. Experience certainly helps. But why? Experience helps in reinforcing the lessons learnt on logic and clinical decision making such as: not to close on a diagnosis too early, and to return to the differential diagnosis if the management of a case does not go to plan. Experience also helps in making the clinician more doubtful and therefore applying more rigorous methods of thought before acting. To paraphrase Oliver Wendall Holmes, a 19th Century physician, – the young doctor knows the rules, but the wise doctor knows the exceptions.

Case reports stimulate learning and research. As a time-honoured tradition of medicine they are capable of developing new subject areas, providing educational material and are among the most read content in journals. Case reports are very sensitive for detecting novelty which is useful in recognising new diseases as well as new side effects of drugs, both adverse and beneficial.

They complement evidence-based medicine. Decisions to withdraw drugs from the market because of harm are usually made on scientific evidence coming from spontaneous case reports (or case series) rather than randomised controlled trials.

A report that is well observed and linked to the published literature can be valuable even if there is nothing unique in the detail of the case. Lessons learnt, documented and shared, even if they are old lessons, are beneficial.

We welcome a range of styles of cases to BMJ Case Reports but they must, at least, identify some new scientific information or have a clear educational message that is useful to a general audience.