The current status of the case report: Terminal or viable?
1 Department of Conservative Dentistry, Faculty
of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
2 Department of Internal Medicine, Faculty of
Medicine, University of Malaya, Kuala Lumpur, Malaysia
3 Department of Biomedical Imaging, Faculty of
Medicine, University of Malaya, Kuala Lumpur, Malaysia
The case report, which has a long history in medicine, has
seen its fortune wax and wane with time. We discuss the challenges facing the
continued survival of the case report, including the inability of journals to
cope with the increased load and increased cost of publication, ethical issues,
the impact factor and the rise of evidence-based medicine. We highlight the
important role that the case report will continue to play in medical research
and education, as a means of sharing information and detecting novelty through
observations. Most importantly, the case report serves as a stepping stone for
young physicians and practitioners into the world of medical writing. � 2009
Biomedical Imaging and Intervention Journal. All rights reserved.
Keywords: Case reports; relevance
Following a motor vehicle accident, an unknown patient was
brought by passers-by to the trauma department. On admission, the patient was
disheveled, unconscious (GCS of 8/15) with lacerations to his scalp, bruising
to the chest and fracture of his left femur. He was not moving his lower limbs.
Following intubation and resuscitation with IV fluids, the patient was sent for
a CT of the head, spine, chest, abdomen and pelvis. There were severe cerebral
contusions with oedema, no shift of midline or evidence of any focal
parenchymal bleed. A comminuted fracture of the L4 vertebral body with
narrowing of the spinal canal was noted. The chest showed lung contusions while
the abdomen did not show any evidence of injury. The great vessels were normal.
Patient was subsequently found to be a Mr. Case Report
(CR). CR was once a very respectable part of the medical research establishment
and was given recognition and space in most medical publications. However, over
the years, due to increased competition, changes in the way his contribution
was being assessed, as well as the increasing commercialisation of medical
publications, CR slowly became sidelined and withdrawn from the readers. At
times, CR was even told not to show his face around the more important original
research reports (ORR), the reviews (R) or even the invited commentaries (IC).
CR went into depression as CR had lost its position in society. The community
was unaware of CR�s plight and there were few who would stand up for CR�s role
and importance. CR become a vagabond and would live in the streets begging for
food. There were two occasions on which CR attempted suicide but this was lost
on his old friends, the ORR, R and IC who were too busy being important. This
current admission to the trauma department was the result of CR jumping off a
bridge, then being hit by an oncoming car.
After decompression and fixation of his spine, CR made a
slow recovery with support from some of his old trusted friends who nursed him
back to health. However, CR never recovered to full function. CR is still no
longer in the limelight but CR is having a new life by being shown in specialty
medical publications who feel that CR must continue to play his role.
History repeats itself; that�s one of the things that�s
wrong with the history
� Clarence Darrow
Seminal early medical texts such as the Chinese Yellow
Emperor�s Classic, the Ancient Egyptian Smith Papyrus, and Hippocrates�
Aphorisms, all expounded methods based on the learning from the authors�
personal cases. Case reports have provided a rich resource for teaching and
research in medicine.
A case report is a detailed report of the symptoms, signs,
diagnosis, investigative results, treatment, complications of treatment, and
follow-up of an individual patient. Case reports  are a brief description of
a case with unique feature/s not previously reported, e.g.
- A positional or quantitative variation of the anatomical structures.
- A previously unreported clinical condition
- An unexpected association between diseases or symptoms.
- A unique or rare features observed while imaging recognised disease or
- A unique therapeutic or interventional technique
- A complication of a radiological procedure or treatment.
Research, which has become an integral part of medical
careers, is based on evidence-based medicine, on the one hand, and genomics on
the other. Evidence-based medicine establishes a strict hierarchy, with CRs
being referred to as anecdotal findings. The CR has been relegated as the
lowest form of medical research with meta-analysis and randomised clinical
trials (placebo-controlled, double-blind studies) being clearly preferred. Yet,
the CR formed an important part of early medical journals long before editors
worshipped at the altar of evidence-based medicine .
For example due to the large backlog of CR, going back
several years in some instances, some journals have resorted to temporary
moratoriums on case report submissions, until some predetermined date, while
more stringent criteria are being established for accepting future case
reports. Others have decided to only publish abstracts online, with the full
content either on the journal or on a professional body's website. There are
also now statements that electronic versions will have faster turn-around than
hard copy submissions. The CR is often deemed to be of lower priority by the
referees, regardless of the impact factor of the journal, which is partly to
blame for the delay in processing the submissions.
Journals that do continue to publish CRs are receiving
more of them and thus, have developed new and more stringent guidelines. A
random search of Pubmed listed 88,516 CR till July 2008, 181,731 case reports
in 2007 and 405,317 in 2006 compared to 74,266 in year 2000. 13.5% (183,349 of
1,355,539) of all the references in the 120 core clinical journals are case reports . Therefore if one desires to see his
or her manuscript grace the pages of a peer-reviewed journal, it needs to be of
high quality .
When it comes to imaging journals, CRs have been removed
completely from some journals e.g. AJR Integrative Imaging Supplement , and
are submitted as a Teaching File instead . CRs are published as a supplement
in others or only available in the online version. Those who continue to treat
it as a vital component of medical education, research and publication, do
accept and publish case reports. There is now even a Journal of Radiological
Case Reports (www.radiologycases.com) which has started to accept case reports.
Journals that continue to accept CRs show varying
acceptance in terms of submission requirements of case reports. Most generally
limit the length, although the required page length varies [7-9]. The number of
figures is also generally stated. Increasingly, imaging journals are beginning
to accept streaming videos with specific formats for the Multimedia file or
even allowing interactive datasets which allow the reader to manipulate and
view the pathology for themselves.
Most journals require the following order of presentation:
- Case Report, and
- Followed by references, tables, and legends.
Why has the CR lost its place in an increasing number of
journals? The opponents� state that:
- A CR is a form of anecdotal evidence; it is therefore less
scientifically rigorous than controlled clinical data involving a larger sample
- The CR has a low level of general application to the practice of
evidence-based care since case reports have certain inherent limitations
- Many CRs are submitted more in the hope of padding out a thin Curriculum
Vitae for career progress rather than with any intention of expanding
- The rampant abuse of gift authorships  is against the ethics of
However, the decreased scientific rigour of the CR may be
due to the failure of the journal/editors/reviewers to evaluate the preparation
and the accuracy of the reports more stringently . Thus journals need not
only ensure strict adherence to concise CRs that provide clear educational
value to the clinician, but also assist the authors with constructive
criticisms on how their submissions can be enhanced. It is therefore vitally
important for journals to publish clear guidelines for authors who plan to
write a case report. The guidelines should specify the length of the
manuscript, number of words, number of figures, and number of references. This
also helps reviewers when reviewing the manuscripts, providing constructive
criticism, and suggesting revisions. It may also be helpful to require authors
to explain in their covering letter/electronic submission exactly why they
think that their CR is of sufficient interest to be considered for publication.
All these requirements will eventually benefit the readers as the journal is
able to provide concise and focused reports that include useful information.
Proponents argue that case reports have value within the
scientific method since they serve as valuable tools for sharing information.
There are several means by which clinicians and scientists communicate with one
another, and these methods of communication can often help determine the kind
of format in which specific forms of information can be shared. For example,
scientists communicate to other scientists via bench research reports, while
clinicians communicate to other clinicians through literature reviews, i.e.
they provide information on all that might be known about a given topic. And
clinicians communicate to scientists through case reports .
The CR ��..permits discovery of new diseases and
unexpected effects (adverse or beneficial) as well as the study of mechanisms
and play an important role in medical education. Case reports and series have a
high sensitivity for detecting novelty and therefore remain one of the
cornerstones of medical progress; they provide many new ideas in medicine� .
Scientific observations in a single case may not prove anything in themselves,
but when presented to a wider audience may trigger larger and more significant
studies . It must also be recognised that medical knowledge has been
traditionally built case by case. If we acknowledge the limitations of the case
report we will not need to neglect its importance in our search for solid
In 1985, the American Medical Association reprinted 51
papers from the Journal of the American Medical Association that had
significantly changed the science and practice of medicine during the 150 years
of the organisation�s existence. Interestingly, 5 of these papers were case
reports . Famous authors of scientific case reports which have been the
basis of progress of medicine have included:
- Sir William Osler, himself the author of many such scientific
observations, encouraged other physicians to �Always note and record the
unusual . . . When you have made and recorded the unusual or original
observation . . . publish it.�
- Sigmund Freud reported on numerous cases.
- Frederick Treves reported on "The Elephant Man".
- Paul Broca reported on language impairment following left hemisphere
lesions in the 1860s.
- Joseph Jules Dejerine reported on a case of pure alexia.
- William MacIntyre reported on a case of multiple myeloma (described in
- The case report on AIDS and Kaposi's sarcoma.
- German psychiatrist Alois Alzheimer first described Alzheimer's disease by
in 1906 .
We are all aware of how we started in medical writing � it
was probably the CR that introduced the uninitiated young physicians and
private practitioners into the research world who otherwise would not have had
access to academic clinical or basic science research. If the CR gets
published, it becomes an asset in the CV of the young doctor which then gives
him or her the pride and courage to proceed along the subsequent phases of
medical research. The CR serves as a �safe� rite of passage without placing too
much at stake, while enabling the development of thought processes geared
towards research. As we all recognise, any kind of research, including writing
CRs, involves a lot of hard work and persistence, which is good training for
the future of our careers.
We have also had numerous instances where images from case
reports have been used to enhance the quality of teaching material e.g.
textbooks, presentations, etc. Case reports can also entertain and interest,
leavening worthy but dry pages of statistical analysis or molecular methods
with some real clinical medicine . Lastly, the act of writing a report
provides an opportunity for one to practise concisely written communication, to
learn about a topic, and to think critically [10,13].
One may wonder why case reports are so popular. Is it because
humans are natural storytellers and case reports are a form of �short� stories?
We have been telling stories for the last 30,000 years. However, about 2,500
years ago, thanks to Plato, Socrates and other ancient Greeks, Western thinking
switched to the mode of inquiry, dialogue, argument and reason when there was
knowledge to impart. While scientific insight and technological breakthroughs
may dominate the practice and teaching of medicine, good old-fashioned
storytelling is increasingly seen as vital in shedding light on the human side
of medicine. With narrative competence, physicians can reach out and join their
patients in illness, recognise their own personal journeys through medicine,
acknowledge kinship with, and duties toward, other health care professionals,
and inaugurate consequential discourse with the public about health care .
Narrative medicine is proposed as a model for humane and effective medical
The economics of publishing, the logistics of the
peer-review, the increased competition between journals, the introduction of
ranking systems e.g. impact factor, as well as other factors have been partly
responsible for the downgrading of the CR. Authors prefer to submit their best
work to journals with the highest impact factors, and these are derived from a
calculation which includes the number of citations made to articles in the
journal. In terms of attracting citations, case reports tend to be at the
bottom of the pile, and therefore it may not be in the long-term interest of
any ambitious biomedical journal to include them in the running order . The
limited page space within a journal therefore tends to be dedicated to
experimental studies which have a higher effect on the journal's impact factor,
unlike the diminutive effect of case reports . With the increased cost of
hard copy publication, the numbers of pages that can be printed are limited,
and the journals have to make a choice of which categories to include in hard
Will the case report continue to be relevant? Our answer
is an emphatic 'yes', especially with the advent of electronic publishing which
has both reduced the cost and increased the speed of sharing information. Along
with its interactive potential, the electronic CR has vast possibilities for teaching
and learning. The trend towards electronic medical publications is evident as
the younger generation is very comfortable with the Internet. We believe that
this generation of young researchers will derive great benefit from CRs and be
driving even higher levels of CR publications. If the novices can be convinced
that the CRs are important, then there is a very strong possibility of markedly
increasing the numbers of future researchers and writers.
���..And besides, if an ectopic pregnancy does ever occur
in the tongue, I would rather read about it (and believe it) in a
well-documented article in one of our respected journals than in a supermarket
checkout magazine.� .
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|Received 13 September 2008; received in revised form 9
November 2008, accepted 26 November 2008
Correspondence: Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Tel.: +603-79492069; Fax: +603-79581973; E-mail: firstname.lastname@example.org (Basri J.J. Abdullah).
Please cite as: Abu Kasim NH, Abdullah BJJ, Manikam J,
The current status of the case report: Terminal or viable?, Biomed Imaging Interv J 2009; 5(1):e4