A piece of the puzzle

From the editor


    The case report is the oldest genre in medicine. It remains as important as ever.

    Photo: Sturlason
    Photo: Sturlason

    The case report sits at the bottom of the pyramid that ranks medical research (1), and when the enthusiasm surrounding evidence-based medicine was at its height, the case report was somewhat overshadowed. Did it seem old-fashioned, passé?

    The Journal of the Norwegian Medical Association publishes case studies in two genres, Short case report and Educational case report (2). The former is suited for brief reports, while the latter follows an entire clinical course from presentation to correct diagnosis. Educational case reports present the history chronologically as it proceeded, and provide an insight into the authors' assessments along the way. The diagnosis is somewhat concealed later on in the text. In this way, readers can be tested on whether they still remember something of what was learned during their medical studies. The discussion section provides space for reflection on whether something should have been done differently. The Journal of The Norwegian Medical Association is intended to be a culture bearer for Norwegian medical science, and at its best the Educational case report contributes to a shared platform and an insight into aspects of medicine that readers do not themselves work with. This is also one of our most widely read genres online, and the articles have a long lifespan there. We believe that the paper versions have an even larger readership.

    An appropriate case for an Educational case report includes a clear point from which others can learn something. Examples may include a condition's unusual presentation, a new treatment method, an unknown adverse effect or interaction, an unexpected clinical course, an ethical dilemma or a reminder of a diagnostic pitfall. If you have been involved in an intriguing case and are able to summarise what you have learned in a couple of sentences, then you probably have the basis for a good Educational case report. Some of the best articles in the genre describe case histories where errors were made. Consistent with human nature in general, and the nature of doctors and medical culture especially, we prefer to talk about the times we excelled. Only the bravest of us write about that time we were mistaken. It is without doubt a gift to our colleagues to report our mistakes, and both for patients and therapists it is meaningful to help others avoid repeating the mistake.

    Even less tempting than writing about one's mistakes is writing about the patient who presents us with a mystery; but perhaps we should more often do precisely this? In evidence-based medicine we like to have studies that include a large number of patients. However, we need n = 1 or n = a few in order to generate hypotheses. Case reports are not only the silt at the bottom of the pyramid, they are also its foundation. It was a humble reader's letter from a doctor who thought he was seeing more deformities in his practice, and wondered if others had observed the same thing, that set the thalidomide scandal in motion (3). In 1981, a Pneumocystis jiroveci infection (previously called P. carinii) was reported in young, homosexual men (4). At around the same time, a dermatologist wrote about widespread Kaposi's sarcoma, also in young men (5). These were the first reports of AIDS. Reports followed of similar symptoms in patients with haemophilia and in infants (6). These were not case reports written by proud doctors (the patients died). The cause of the immune failure was unknown. The case reports were written in a state of bewilderment, about clinical courses that were not understood. What is sad is that the cases were first reported when there was an accumulation. No one wrote about the young Norwegian girl with severe immune failure who died in January 1976 at the age of eight (7), nor when her father, a former sailor, died a few months later. Her mother died in December of the same year. However, the fact that no one wrote about the family did not mean that no one gave thought to it. Twelve years later, new analyses of blood samples from the family were performed, and the diagnosis was confirmed. The cases were then reported, and the family is now considered to be the very first documented case of AIDS (8). There must have been more individual cases around the world that were not reported. We can only speculate how history might have looked if we had been given four or five years' head start in the AIDS epidemic.

    The same applies to rare diseases. If more doctors reported the rare cases, perhaps new patterns would be discovered? Our genre Short case report is suited for the reporting of unusual cases. Since all our case reports are indexed in PubMed with summaries in English, they are available and searchable for doctors throughout the world.

    The puzzle will not be completed without first placing the pieces on the table.


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