Patients, are they the silent contributor to case reports?

Patient participation (wikipedia CC)

We are in currently in the process of putting together a case report following a toxicological emergency in the ED. It’s an interesting case, deals with new street drugs and has some great lessons for emergency management…., well we would say that wouldn’t we, every case report author from the dawn of time has said the same…., but that’s not the point today.

Rather, as part of the writing process it is important to gain consent for publication. This is a routine requirement for any case report in the literature and here within the BMJ group you can visit the BMJ case reports website where the absolute and explicit requirement for patient consent is stated. The consent form is available in an impressive 13 languages so we obviously take this very seriously. Similarly there are explicit and clear(ish) instructions for authorship and contribution within the group as we clearly want those with their names at the top of the paper to have made a substantial and important contribution to the work. Authorship is defined differently to contributorship and it would be rare for patients to meet the following 4 criteria as lead out by ICMJE.

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Requirements for authorship.

I don’t think you need to be too clever to see where this is going. In a case report it is surely the patient who makes the most substantial contribution to the paper as without their involvement there is no case. Should we therefore offer patients the opportunity for acknowledgement on case reports?

Now you may argue that we need to protect patient confidentiality and that’s true so this could only ever function as an opt in rather than as an opt out, but should we at least offer the possibility of opting in? Those with paternalistic tendancies may argue that there are risks in patient identification. Coercion, willingness to please and the possibility that initial enthusiasm may subsequently turn in to a regret from sharing are clearly possible although the current trends in social media suggest that many patients share their injuries and illnesses in public forums already. My experience is that many patients are delighted to share their cases and some have expressed a wish to be acknowledged in publication, but as things currently stand it is unclear how to deliver this.

Patient involvement in publication is increasing. Examples exist such as the Patient Perspective series in journals such as the BMJ, but these are written contriubtions from patients with the time, talent and inclination to write. That is not typical of patients in case reports and in some cases it may not be possible for them to do so.

The ICMJE defines contributorship as non-authorship listing a number characteristics and ways of defining what constitutes authorship. Interestingly and perhaps disappointingly the contribution of the patient (the case of the case report) is missing. Examples include ‘caring for the patient’ but not ‘being the patient’ which I find a little strange and again somewhat paternalistic.

So, I ask the question of the readers, the editors and any patients who might be out there. If a patient wishes to be acknowledged as a contributor to the education of clinicians, should we make it happen, and if so how?



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