Applause for case reports

I was pleased to learn that Canadian Family Physician (CFP) is reintroducing case reports in the journal.¹ As stated in Dr Pimlott’s editorial,¹ 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.²

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 Reid³ explained, family physicians often find it difficult to talk about their work without describing their patients.

A case report, as described by Morris,⁴ presents a unique case, a case of unexpected association, or a case of unexpected events. Case reports play a considerable role in medical education, whether they occur in short form at the bedside, in the office corridor, or at grand rounds presentations. With case reports, teachers can highlight to learners those aspects of a patient’s illness that they consider most important. Case reports aid in education around clinical reasoning and coping with the uncertainty⁵ that so often characterizes medicine, especially family medicine. They are important in developing professional identity,⁶ standards of practice,⁷ and ethical values.⁸

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,⁹ a section in its journal comprising articles that focused on patients’ psychosocial, economic, and environmental circumstances; reviewed standard biomedical information; and included statements from patients about the dilemmas they faced. The goal of Clinical Crossroads articles was to inspire reflection in the style of the early grand rounds presentations, which generally included bringing a patient before the audience. The patients who were described in Clinical Crossroads articles were demonstrations of physical findings; however, their perspectives were also integral to the presentation.

For half a century, journals that focus on family practice—such as CFP and British Journal of General Practice, both of which began publication in the early 1950s— have served to help develop the knowledge base of the discipline. Family medicine literature ensures that family physicians not only understand appropriate biomedical frameworks but also recognize the critical importance of the patient-doctor relationship, a patient’s experience with an illness, and the context in which patients 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 make each case unique. We must bring the patient back to the centre of our case reports.

The format of patient-centred case reports serves to highlight patients’ experiences with their illnesses and key contextual factors, and to 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.¹⁰

I urge CFP to welcome the patient-centred case report format, recognizing that it celebrates patients, their family physicians, and 50 years of research evidence.

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