Two cheers for case reports

I was pleased to learn that CFP is re-introducing case reports in the journal.

As stated in the editorial, case reports have a history rooted in the origins of medicine. Their importance was clearly recognized in the emergence of modern medicine in the early 20th century even as it sought to emphasize the integration of new scientific knowledge (Cannon, 1900).

Even as Evidence Based Medicine moved case reports to the bottom of the 'knowledge hierarchy', physicians have never ceased relating cases to one another. It is often how we talk to one another. As Reid (1982) found, family physicians often find it difficult to talk about their work without describing their patients.

Case reports are made for a variety of reasons. Morris (1991) described three: 1) a unique case, 2) a case of unexpected association, and 3) a case of unexpected events. They play a major role in medical education, whether they occur in short form at the bedside, office corridor or at Grand Rounds presentations. They are recognized as critical in imparting to learners those aspects of their patient's illness that their teachers consider most important. They aid in education around clinical reasoning and coping with the uncertainty (Holmes, Ponte, 2011) that so often characterizes medicine, especially family medicine. They are important in developing professional identity (Jarvis-Selinger, 2011), standards of practice (Spafford et al, 2004) as well as ethical values (Charon, Montello, 2002).

Balancing the particulars of the case with the evidence serves to develop the practical knowledge that distinguishes the accomplished clinician from a competent technician. In 1995 JAMA introduced Clinical Crossroads (Delbanco, Daley, Walzer, Winker, 1995) that explicitly included the psychosocial, economic and environmental circumstances of the patient, in addition to the standard biomedical information. Also, importantly, the patient's statement of the dilemma they faced is a part of the case. This was intended to reflect, in a print format, the style of the early Grand Rounds which generally included bringing a patient before the audience. It differed from those early days in that in Clinical Crossroads patients were included for more than simply demonstration of physical findings. Their perspective formed an integral part of the presentation.

For almost 50 years, journals that focus on family practice, such as Canadian Family Physician and British Journal of General Practice, both of which began publication in 1955, have served to help develop the knowledge base of the discipline. The family medicine literature has made clear that, as well as knowing the appropriate biomedical framework, the family physician recognizes the critical importance of the patient/doctor relationship, the patient's illness experience, and the context in which they live in order to reach common ground for provision of care. It is important that case reports reflect the values and accumulated knowledge of the discipline of family medicine. Too often case reports are focused exclusively on the biomedical aspects of the patient and completely leave out the very human aspects that makes each case unique. We must bring the patient back to the centre of our case reports.

The Patient-Centred Case Report provides a format that serves to highlight the patient's illness experience and key contextual factors as well as reflect on the patient/doctor relationship. These elements are in addition to the usual biomedical factors. Such case reports are very useful in education of family medicine residents and for continuing professional education (Freeman, 2014).

I urge that the Patient-Centred Case Report format be welcomed by CFP, recognizing that it celebrates patients, their family physicians and 50 years of research evidence.

Cannon WB. 1900. The case method of teaching systematic medicine. Boston Med Surg J. 142:31-36.

Charon R, Montello M (eds). 2002 Stories Matter: The Role of Narrative in Medical Ethics. New York, NY: Routledge.

Delbanco TL, Daley J, Walzer J, Winker MA 1995. Clinical Crossroads: An Invitation JAMA 274(1):76-77.

Freeman TR 2014. The Case Report as a Teaching Tool for Patient-Centered Care. In: Stewart MA, Brown JB, Weston WW, McWhinney IR, McWilliam CL,

Freeman TR. Patient-Centered Medicine: Transforming the Clinical Method. Radcliffe Publishing, London, New York.

Holmes SM, Ponte M. En-case-ing the Patient: Disciplining Uncertainty in Medical Student Patient Presentations. Cult Med Psychiatry 35:263-82.

Jarvis-Selinger S, Halwani Y, Joughin K, et al. 2011.Supporting the Development of Residents as Teachers: Current Practices and Emerging Trends. Members of the FMED PG Consortium.

Morris BAP 1991. Case Reports: Boon or Bane? In: Norton PG et al (eds). Primary Care Research: Traditional and Innovative Approaches. Newbury Park, CA: Sage.

Reid M 1982 Marginal man: The identity dilemma of the academic general practitioner. Symbolic Interaction 5(2):325

Spafford MM, Lingard L, Schryer CF et al. 2004. Tensions in the field: teaching standards of practice in optometry case presentations. Optom Vis Sci 81(10):800-6.

Conflict of Interest:

None declared