Dermatology Online Journal

Ode to the case report
Ted Rosen, MD
Dermatology Online Journal 14 (4): 1

Baylor College of Medicine, Houston, TX. vampireted@aol.com

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Abstract

Although many medical journals routinely shun publication of case reports, these communications still can play a major educational role. Unexpected presentations, heretofore unreported adverse events and new associations may be illuminated. Although not as rigorous as placebo-controlled, double-blind studies, case reports do have a high degree of sensitivity for detecting novelty. Thus, they may also serve a useful purpose in directing future investigation.

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How many newly minted authors (translate: students, residents and junior faculty) have had their aspirations dashed by a journal rejection typically stating that: "This report was not given a high enough priority to warrant publication?" With regards to case reports, this is an ever-increasing phenomenon, especially when the work has been submitted to a "high impact" journal. In a world run, in large part, on avarice and the never-ending quest for profit margins, it is not surprising that the world of medical publishing is no different. Journals, and the companies that publish them, use the impact factor to tout the journal's visibility, importance, prestige, and quality. This is analogous to the Nielsen ratings for television shows or the Arbitron ratings for radio programming. To maintain a high impact factor becomes a goal unto itself, because this then justifies placement of medical advertisements and insures a goodly share of pharmaceutical industry advertisement dollars. The impact factor is essentially determined by how often articles from any given journal are cited in other medical publications. Editors feel, and rightly so, that case reports stand a lower chance of being cited elsewhere. Indeed, a recent study published in JAMA disclosed that case reports receive the fewest citations of all other study designs. In a group of 416 case reports published between 1991 and 2001, less than two percent received 10 or more citations in the first two years following publication [1]. Thus, publication of too many case reports may lower a journal's impact factor and, as a potential consequence, also lower advertising revenue. Scientific merit plays little to no role in this decision. Financial considerations are paramount. To their credit, some journal editors have come right out and admitted this, while others continue to turn away fascinating case reports under the subterfuge of "low priority" following peer-review.

Is there any benefit to publishing case reports? The answer, in my opinion, is a resounding affirmative. What can be learned from a case report? The reader might become familiar with an unexpected or unusual presentation of a disease or of a heretofore unreported side effect or adverse interaction involving a medication. In fact, it is often case reports that call attention to adverse events which went unnoticed during pivotal drug trials and are either unreported to the pharmaceutical company or FDA (or even deliberately hidden) during post-maketing surveillance [2]. New associations between disease processes might be suggested. New or emerging diseases might be demonstrated to alert the reader to them, thereby facilitating both timely diagnosis and management. An unexpected event in the course of observing or treating a patient might shed new light on the possible pathogenesis of a disease. A novel treatment might be highlighted; if it worked for the author, perhaps it will work for the reader! If nothing else, the case report can serve the same purpose as all continuing medical education: an educational role in reminding the readers of something they might have forgotten because they have not been forced to deal with the subject matter in some time [3]. In fact, most case reports are representative of the usual diagnostic mysteries and therapeutic challenges a clinician faces in the everyday practice of medicine [4]. These are but a few tangible benefits from publishing (and reading) case reports.

On a less serious note, case reports can be just plain fun to peruse. There is entertainment value, along with pragmatic medical value, in many case reports; the paper may appeal to the Sherlock Holmes in all of us! Think of famous case reports from a historical perspective: Frederick Treeves and the "Elephant Man" or Sigmund Freud and "The Rat Man." Surely these are as entertaining as they are informative.

It is certainly true that case reports are anecdotal in nature and, as such, are less scientifically rigorous than double-blind, placebo-controlled trials with a large sample size. No one disputes this. Nonetheless, case reports and case series have a high sensitivity for detecting novelty and therefore remain one of the cornerstones of medical progress [5]. Although seemingly contradictory, case reports can also be founded in and rely heavily upon evidence-based medicine [6]. In this scenario, case reports extend or validate accepted evidence-based dogma.

Luckily, the Internet and electronic publishing has fostered a revival of sorts for the lowly case report. A plethora of open access Internet journals literally cater to publication of case reports. Radiology Case Reports, published by the University of Washington; Case Reports in Gastroenterology. Published by Karger; and the Journal of Medical Case Reports, published by BioMedCentral are but a few examples. A novel fiscal model, payment of a fee to defer the cost of publication, allows for such publications to exist free from the constraints of traditional advertising revenue and the tyranny of the impact factor. Of course, even this new model engenders concerns: transferring the cost for publication to the authors threatens less-affluent clinicians and researchers, particularly those from developing nations, whose grants may not provide sufficient funds to publish their work [7].

The Dermatology Online Journal reflects the best of both worlds: rapid, open access communication without a publication fee. Case reports form the backbone of DOJ, but are not its sole type of communication. Research studies, case series, reviews, and even commentaries (like this one) may be published. This issue of DOJ comes from the Dermatology Department at Baylor College of Medicine. We hope that you will enjoy the primarily case-based submissions and trust that there is something to learn, or at least enjoy, herein.

References

1. Patsopoulos NA, Analatos AA, Ioannidis JP. Relative citation impact of various study designs in the health sciences. JAMA. 2005 May 18;293(19):2362-6. PubMed

2. Vandenbroucke JP. Case reports of suspected adverse drug reactions: case reports were dismissed too quickly. BMJ. 2006 Feb 25;332(7539):488. PubMed

3. Vandenbroucke JP. [The importance of case reports as compared to evidence-based medicine and molecular explanation] Ned Tijdschr Geneeskd. 2002 Sep 7;146(36):1699-703. (Dutch) PubMed

4. Falagas ME, Fragoulis KN, Kopterides P. An analysis of the published Massachusetts General Hospital case records (1994-2004). Am J Med. 2005 Dec;118(12):1452-3. PubMed

5. Vandenbroucke JP. In defense of case reports and case series. Ann Intern Med. 2001 Feb 20;134(4):330-4. PubMed

6. Perry IJ. Evidence based case reports. Undergraduates in Cork have to submit them during their course. BMJ. 1998 Nov 14;317(7169):1386-7. PubMed

7. Benítez-Bribiesca L.The dawn of a new era of biomedical publication. Arch Med Res. 2005 Jul-Aug;36(4):309-10. PubMed

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