The case for … writing case reports

“Always note and record the unusual…Publish it. Place it on permanent record as a short, concise note. Such communications are always of value.”

– Sir William Osler

It seems that with the emergence of the era of evidence-based medicine, the case report has become less valued in the medical literature (1). Despite this trend, 250,000 case reports were listed on MEDLINE over a five-year period beginning in 1997. Sixty-five per cent of the 250 journals on the British Medical Association’s ‘Hague list’, including the British Medical Journal, The New England Journal of Medicine and the Lancet, still publish case reports (2). The nature of research evidence may be population based, but our teaching and clinical practices continue to be influenced by case-based observations. Humans thrive on stories, and even the most obscure clinical pearl can be made memorable if attached to a real event or actual person. I believe that clinicians enjoy reading case reports and find them helpful in everyday practice.

WHY BOTHER?

The case report is a perfect authorship opportunity for trainees and practising clinicians; appropriate cases will appear, and intuitively you will know what will be helpful and of interest to your colleagues. It is also reassuring for the busy clinician that much of the preparatory work is already done, as a result of the discussions and reading needed to make good diagnostic and management decisions. Putting pen to paper will sharpen your written communication skills and critical thinking. Seeing your work in print will give you a sense of satisfaction and may lead to further scholarly work.

HOW TO BEGIN

In their commentary in the present issue of the journal (pages 339–342), MacDonald et al provide further detail about strategies for beginning the writing process. Deciding which case to report should not be an insurmountable barrier. Different journals publish different kinds of cases. Some may be looking for originality (3); others, including Paediatrics & Child Health, consider the educational value and usefulness for the reader to be more important than uniqueness. You need to target your audience and journal by reviewing what types of case reports have been published in the journal in the past and their ‘instructions to authors’ pages. If in doubt, you may want to contact the editorial staff of the journal you are considering to discuss your intentions before starting.

It is essential that you obtain written consent from the patient’s family and the patient, if appropriate, and document that consent on the patient’s chart (4). On very rare occasions – for example, in cases of child abuse – consent may not be appropriate. Some journals now have their own consent forms, which have to be completed by the patient or parent. Some cases benefit from a photograph.

WHAT DO EDITORS LOOK FOR IN A SUBMISSION?

Journal editors differ in what they look for in a submission, but a review of the instructions to authors in 163 medical journals revealed a median limit of 1000 words, eight references and six authors for case reports (2). Approximately 90% of the journals requested an abstract and key words. In this era of electronic databases, it is essential that you provide this information if you want your report to be accessible to the reader. Sixty-one per cent were looking for unusual or rare content, while 55% requested that the content be instructive. In your cover letter to the editor, make sure that you sell your manuscript by articulating the salient educational message. Brevity and clarity are essential assets if a submission is to meet the journal’s space requirements and retain the reader’s interest.

HOW TO STRUCTURE THE REPORT

Focus on your single educational message. Start with a brief abstract and a list of key words. The case description follows, and should contain the essential details and relevant test results, with normal values in parentheses. The discussion section comes next. The theme should be your educational message. Cite the literature only as needed to make your point; do not present your entire literature review. A review article is very different from a case report. Highlight the significance of what you are presenting and what your colleagues should learn – clearly and briefly! End with a summary or conclusions paragraph, which is generally your take-home message.

HOW TO MAXIMIZE THE CHANCE OF PUBLICATION

In Table 1, the factors that are particularly important in producing a manuscript that will be accepted for publication are summarized. They have been dealt with in the preceding sections of the present paper. An additional key issue arises when criticisms or a rejection is received from a journal after the paper has been submitted. Almost all case reports will require revisions as suggested by the peer reviewers. Address each point carefully and clearly with an accompanying letter explaining the changes. Do not take rejection personally because it does not necessarily reflect the quality of your report. You may need to target your audience a bit more carefully with your resubmission. If your case report is very brief or is rejected in its current format, you may consider resubmitting it as a letter to the editor.

TABLE 1.

Factors that enhance the chance of manuscript acceptance

Obtain written, informed consent and maintain confidentiality*

Target audience or journal according to your message

Consider discussing ideas with the editorial staff before starting

Collaborate with a content expert, if appropriate

Focus on a single educational message

Avoid an exhaustive literature review

Aim for brevity and clarity

Put careful thought into the cover letter

^*See reference 4

If you feel inspired to write, do not procrastinate – read the accompanying article by MacDonald et al and begin! The ‘Clinician’s Corner’ in Paediatrics & Child Health is one way to share your educational case with other paediatricians and family physicians throughout Canada and beyond.