Volume 4 | Issue 1 | JOCR Jan-Mar 2014 | Page 1-2 | Shyam AK
Only Rare Cases are Case Reports: Busting a Myth
Author: Ashok Shyam
Editor – Journal of Orthopaedic Case Reports. Email: firstname.lastname@example.org
Only Rare Cases are Case Reports: Busting a Myth
Being the editor of Journal of Orthopaedic Case Reports, I encounter a variety of queries and questions regarding the nature of Case Reports. Often when I point that a particular case can be presented as a case report, I get a reply that it is not a rare case, can it be published? Even at other times when I point that an image, or a technique or even an idea can be published, the same counter comes confronting. It seems a lot of us do believe that case reports can be published only if they are rare cases, or cases that are never presented before or something to similar tune. In this editorial I shall try to encounter this myth in as many perspective as I can.
To begin with I call the idea of case reports being rare as a ‘Myth’. Something that is not completely true but widely believed at. So am I saying that the statement is false? No, I simply imply that it is just part of the truth and not the complete perspective and being in narrow field of context leads to such dominating myths. To understand this, one must have a look at history of medical literature. For thousands of years, Case Reports were the only kind of literature that were published [at the most a series of case reports]. This comprised the learning treatises and books in all recorded human history till last one hundred years. Case reports have served as the valid and reliable form of literature, although their validity did not lie with individual cases but with pool of cases. If we look at the legal literature it still depends on these individual case reports [or hearings] for making a statement or offering a defense. So what happened to medical literature and why did case reports lose their shine? There are many top journals in orthopaedics today who have stop publishing case reports. Has the reader ever wondered why? Well it is not because case reports are not important or they are redundant or they don’t add value to literature. No, it is because case reports do not count in the number game of ‘impact Factor’. As we know impact factor is calculated by number of citations an article gets. Case reports are said to be cited infrequently and thus are believed by the journal to reduce their impact factor. Thus when one journal stopped accepting case reports their impact factor was perceived to be rising. Looking at this most of the journal stopped accepting case reports. Thus it had nothing to do with the value or importance of case reports but simply due to number games among journals (sic). Anyways now that I have clarified that lets get back to our question of whether the case reports comprise only of rare cases. Rare cases are of course part of the case report spectrum, but the spectrum is quite wide. As mentioned earlier, case reports have been used historically as case pools [inferences from a series of similar cases]. In this sense, I believe every case in orthopaedics has potential for publication. As orthopaedic surgeons we recognize that no two patients are similar, in terms of fractures, severity of diseases, comorbidities, social, financial and geographical contexts. Every patient presents a unique scenario and answer for every problem cannot be found in literature or guidelines. This specifically applies to fracture cases where we are still struggling to classify them. Other cases belonging to this categories are delayed presentations, presentations at unusual age, complex of complicated cases, primarily difficult cases, cases where two [or many] different schools of thought exist for management, cases that do not fit any existing classification or treatment model and lastly cases that have unique racial, geographical and socio-economic overtones. We know each case requires a personalized approach to decide the ‘Optimal’ treatment to achieve realistic results [contrary to unrealistic paradigm of best treatment for best results, which we know is purely utopian and has not worked since its introduction decades ago]. This clinical decision making requires a very specific thought process and this though process is again a very good and academic material to publish as a case report. Thus the entire decision making including the differential diagnosis, management options and decision algorithm for each case is publishable as a case report. JOCR has started the idea of ‘Case Study’ which can be utilized to report such decision making algorithm. As surgeons we are many a times forced to improvise during surgeries or during management of particular patient. The thought process behind these improvisations and their results can also be published as case reports. Technical notes on these improvisation can be published as techniques and videos. Many a times we see cases or images, radiographs which defy commonplace thinking or are something that stimulates lot of lateral thinking. These images, radiographs can be published as case reports. Complications are major thing in this sense of stimulating a thought process. Every complication can be and should be published, but the publication should include a clear idea of why the complication occurred and how it can be avoided. In fact our new journal ‘Journal of Orthopaedic Complications’ is dedicated to this concept. Sometimes based on our experiences or observations there are certain guidelines which are formed, these guidelines or algorithms are based on lifetime of observations and experiences. These can be clearly demonstrated with use of a particular case. These can also be published as a case report. Again a revolutionary kind of format will be soon introduced named ‘Case Pool’ where we will try to replicate the historical case report paradigm. We will start case pools of various common and uncommon cases [like registries], these will be published in the journal and at regular intervals all cases in the pool will be analyzed to draw clinical inferences. This idea is still in its early days and we will work on it in more details. However this will meet our end that every case is publishable and every case should be published.
I believe literature is a way where we try to share our experiences and insights and not only play of numbers and statistics. In the run of the number game, personal experiences have been looked down upon and almost shunned at many places in the world, but I believe we have moved from one extreme of believing only personal experiences to other extreme of believing only statistical literature. I believe the truth lies somewhere in a balance of both. At pretext of making observation more objective the entire premise that patient treatment is still a very subjective science [and it should be] is been overlooked. Statistics and the evidence paradigm have their importance but should not and cannot replace a surgeon’s rational decision making ability. And even today if we observe, we treat a lot of patients from our own personal decision making algorithm. What we read in books, journals, what we listen in conferences, what we discus with our colleagues and what we were taught in our training days and most importantly our own personal experiences with our patients, all have contributing effect on this algorithm and help it evolve and develop. Literature and Evidence cannot and should not replace this. The science of probability is still too lacking to bind all our concepts and come up with a subjectivity-proof algorithm. But the main question is, do we need such an algorithm and will we ever agree to such. I have seen surgeons who have been practicing a particular technique for years and have excellent results. Should they change their practice because EBM says so? The pain of being discredited by a bunch of intangible formulas is much palpable in our senior generation. Like I mentioned everything has its role and place and the truth lies somewhere in balance of these subjective and objective paradigms. Case reports are something that are placed uniquely at the crux of these paradigms. These can be very well used to bridge the gap between these prevalent outlooks and should be used to this end. Thus a well written case demonstrating a personal algorithm, or personal experience is very much a part of case reports spectrum. This when discussed in context with current literature forms a common grounds for meeting place of Experience and Evidence. I could go on and on in presenting the importance of Case Reports and expanding its spectrum, but I think it will suffice to say that in orthopaedics every case is publishable [either as a case report, case series or case pool] and once we start looking at every case as potentially publishable, we will start understanding on how to present the case and in what context. I believe guidelines of JOCR are descriptive enough and if anyone wishes to know whether his case can become a case report, he can write to us directly by email with details of his case. Another suggestion will be read all the editorials of JOCR since the beginning where we have tried to touch upon these points from various aspects. I hope I have expanded your vision about case reports and hopefully will stimulate a lot of you to publish your cases. Do write to us your opinions and suggestions about JOCR.
Dr Ashok Shyam (MS Ortho)
Editor – Journal of Orthopaedic Case Reports
1. Shyam AK. JOCR: Personalised Journal, Personalised Network and Clinical Decision Making (CDM). Journal of Orthopaedic Case Reports 2012 Oct-Dec;2(4):2-3.
2. Shyam AK. Editorial – A Single Observation can Change a Paradigm. Journal of Orthopaedic Case Reports 2013 Jan-March;3(1):1-2
3. Shyam AK – Wisdom of the Crowds: Extending the Domain of Medical Information to Case Banks and Online Forums. Journal of Orthopaedic Case Reports 2013 Jan-March;3(1):1-3
4. Shyam AK. Research! Research! Research! What are Thou?. Journal of Orthopaedic Case Reports 2013 July-Sep;3(3):1-2.
5. Shyam AK. How to write a Case Report for Journal of Orthopaedic Case Reports– What do Editor and Reviewer want? Journal of Orthopaedic Case Reports 2013 Oct:Dec;3(4):1-2.
How to Cite This Article:
Shyam AK. Only Rare Cases are Case Reports: Busting a Myth. Journal of Orthopaedic Case Reports 2014 Jan-Mar;4(1):1-2.
Available from: https://www.jocr.co.in/wp/2013/10/21/2250-0685-120-fulltext/
Dr. Ashok Shyam