Editorial
Case Reports in the Era of Evidence-Based Medicine
C
William W. Hurd, MD, MPH
Dr. Hurd is Associate Editor (Gynecology) for Obstetrics & Gynecology and Professor and Director of the Division of Reproductive Endocrinology and Infertility at Duke University School of Medicine, Durham, North Carolina; e-mail: whurd@ greenjournal.org. Financial Disclosure The author did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/14
ase reports remain a valued part of the medical literature, despite dramatic changes in the way we receive medical information.1 Over the past century, case reports have evolved from the arcane purpose of reporting rare or unusual conditions to the more pragmatic role of helping clinicians accurately diagnose and appropriately treat less common maladies. This latter role is embodied in the term “clinical teaching point,” which will be a required component of every case report published in Obstetrics & Gynecology starting in 2015. As of July 1, 2014, we will be asking authors to include a list of teaching points—one to three lessons for clinical management that derive from their case—at the end of their article. A clinical teaching point can be defined, for the purpose of case reports, as information intended to help clinicians with unusual diagnostic or therapeutic problems. A clinical teaching point potentially can change the way clinicians either 1) comprehend a presenting symptom or test result or 2) approach treatment. When confronted with any collection of sign and symptom, it is human nature for the clinician first to consider the most common diagnoses. Many case reports remind us of the less common, but no less important, “zebras” that we sometimes encounter. Other case reports introduce us to new diagnostic or treatment approaches. A case report is of limited value if it does nothing more than describe a rare condition. Before the modern information age, case reports were the primary method used to document rare conditions and to provide a forum to discuss their diagnosis and treatment. After a number of years, similar cases could be enumerated and the incidence estimated using contemporary data as the denominator. In recent times, the existence of massive databases and online information repositories has filled these needs. Today, case reports of rare conditions are helpful only if they elucidate emerging new medical challenges, such as the increased rate of vaginal cuff dehiscence observed in the early days of robotically assisted laparoscopic hysterectomies.2 One might ask, “Are case reports still relevant in the era of evidencebased medicine?” We have been taught that clinicians should resist the temptation to practice based on how we have been “burned”; that is, those memorable (and sometimes troubling) cases that did not turn out the way we wanted. Clearly, it is difficult to draw conclusions from a study with “an n of 1.” However, the majority of diagnostic and therapeutic approaches have not been subjected to scientific study, and many never will be. In addition, it is often difficult to apply the results of population-based research to the care of an individual patient.3 Case reports can be stimulating and thus memorable to the reader in ways that studies cannot. As clinicians, we all have experienced situations in which we are at a loss as to what to do next in terms of either diagnosis or treatment. In some situations, most notably responses to therapeutic
VOL. 124, NO. 2, PART 2, AUGUST 2014
OBSTETRICS & GYNECOLOGY
409
complications or life-threatening emergencies, the emotional response will make a particular case memorable for a lifetime. When a case report is skillfully written, readers can experience an emotionprovoking diagnostic or treatment dilemma in the comfort of their offices. An important role of case reports is to share experience, particularly in the area of diagnosis. The art of diagnosis remains difficult to quantify, and thus is uncommonly the subject of scientific study. The hope is that, if we read about the difficulties others have had, particularly when making a diagnosis, we will be better equipped to make the correct diagnosis when faced with similar symptoms and test results. Well-written case reports allow us to sharpen our skills when it comes to responding to uncommon diagnostic or treatment situations. Many readers find satisfaction in a case report when their clinical acumen allows them to make the correct diagnosis and choose the appropriate treatment for the unusual condition. Difficult cases give readers new insights that hopefully allow them to better treat similar cases in the future. This is particularly important when a relatively uncommon condition (eg, uterine rupture during pregnancy) occurs as a result of a relatively new treatment (eg, uterine artery embolization) or when new or more effective treatment modalities become available for any condition.4 Reading case reports of less common clinical situations serves a purpose similar to pilots’ flight simulators. Experienced pilots do not “fly simulators” to improve their skills at routine takeoffs and landings. Rather, simulator training allows the pilot to review and reinforce the recognition of and appropriate response to uncommon emergencies. If such a situation occurs in real life, the pilot is more likely to respond effectively even if it is the first time he or she has experienced it. Good case reports can prepare clinicians for the unexpected.
410
Hurd
Since 1976, case reports have appeared separately from main journal content, first in a special supplement to Obstetrics & Gynecology sponsored by an advertiser and then later evolving to “Part 2” issues of the journal published twice yearly.5 The advantage of publishing case reports separately is that a large number of cases can be read in a single issue, and these less-scientific reports are less likely to distract readers from the research articles and review articles published in the regular monthly issues. The disadvantages are that publication of individual case reports sometimes is delayed and Journal readers have to make an extra effort to read them. Beginning in January 2015, case reports again will be included in each regular issue of Obstetrics & Gynecology. The number of case reports will be limited to avoid inordinately increasing the page count of the each issue. Efforts will be made to keep case report topics balanced between the obstetrics field and the gynecology field. Only the best of the best will be published, and we will continue to ensure that each case report contains clear clinical teaching points. We hope that the return of case reports to each issue will be of value to Obstetrics & Gynecology readers. REFERENCES 1. Scott JR. In defense of case reports. Obstet Gynecol 2009;114: 413–4. 2. Robinson BL, Liao JB, Adams SF, Randall TC. Vaginal cuff dehiscence after robotic total laparoscopic hysterectomy. Obstet Gynecol 2009;114:369–71. 3. Tonelli MR. The philosophical limits of evidence-based medicine. Acad Med 1998;73:1234–40. 4. Yeaton-Massey A, Loring M, Chetty S, Druzin M. Uterine rupture after uterine artery embolization for symptomatic leiomyomas. Obstet Gynecol 2014;123:418–20. 5. Pitkin RM. The Green Journal history: 50 years on. Washington (DC): American College of Obstetricians and Gynecologists; 2003.
Case Reports in the Era of Evidence-Based Medicine
OBSTETRICS & GYNECOLOGY
Case Reports in the Era of Evidence-Based Medicine
C
William W. Hurd, MD, MPH
Dr. Hurd is Associate Editor (Gynecology) for Obstetrics & Gynecology and Professor and Director of the Division of Reproductive Endocrinology and Infertility at Duke University School of Medicine, Durham, North Carolina; e-mail: whurd@ greenjournal.org. Financial Disclosure The author did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/14
ase reports remain a valued part of the medical literature, despite dramatic changes in the way we receive medical information.1 Over the past century, case reports have evolved from the arcane purpose of reporting rare or unusual conditions to the more pragmatic role of helping clinicians accurately diagnose and appropriately treat less common maladies. This latter role is embodied in the term “clinical teaching point,” which will be a required component of every case report published in Obstetrics & Gynecology starting in 2015. As of July 1, 2014, we will be asking authors to include a list of teaching points—one to three lessons for clinical management that derive from their case—at the end of their article. A clinical teaching point can be defined, for the purpose of case reports, as information intended to help clinicians with unusual diagnostic or therapeutic problems. A clinical teaching point potentially can change the way clinicians either 1) comprehend a presenting symptom or test result or 2) approach treatment. When confronted with any collection of sign and symptom, it is human nature for the clinician first to consider the most common diagnoses. Many case reports remind us of the less common, but no less important, “zebras” that we sometimes encounter. Other case reports introduce us to new diagnostic or treatment approaches. A case report is of limited value if it does nothing more than describe a rare condition. Before the modern information age, case reports were the primary method used to document rare conditions and to provide a forum to discuss their diagnosis and treatment. After a number of years, similar cases could be enumerated and the incidence estimated using contemporary data as the denominator. In recent times, the existence of massive databases and online information repositories has filled these needs. Today, case reports of rare conditions are helpful only if they elucidate emerging new medical challenges, such as the increased rate of vaginal cuff dehiscence observed in the early days of robotically assisted laparoscopic hysterectomies.2 One might ask, “Are case reports still relevant in the era of evidencebased medicine?” We have been taught that clinicians should resist the temptation to practice based on how we have been “burned”; that is, those memorable (and sometimes troubling) cases that did not turn out the way we wanted. Clearly, it is difficult to draw conclusions from a study with “an n of 1.” However, the majority of diagnostic and therapeutic approaches have not been subjected to scientific study, and many never will be. In addition, it is often difficult to apply the results of population-based research to the care of an individual patient.3 Case reports can be stimulating and thus memorable to the reader in ways that studies cannot. As clinicians, we all have experienced situations in which we are at a loss as to what to do next in terms of either diagnosis or treatment. In some situations, most notably responses to therapeutic
VOL. 124, NO. 2, PART 2, AUGUST 2014
OBSTETRICS & GYNECOLOGY
409
complications or life-threatening emergencies, the emotional response will make a particular case memorable for a lifetime. When a case report is skillfully written, readers can experience an emotionprovoking diagnostic or treatment dilemma in the comfort of their offices. An important role of case reports is to share experience, particularly in the area of diagnosis. The art of diagnosis remains difficult to quantify, and thus is uncommonly the subject of scientific study. The hope is that, if we read about the difficulties others have had, particularly when making a diagnosis, we will be better equipped to make the correct diagnosis when faced with similar symptoms and test results. Well-written case reports allow us to sharpen our skills when it comes to responding to uncommon diagnostic or treatment situations. Many readers find satisfaction in a case report when their clinical acumen allows them to make the correct diagnosis and choose the appropriate treatment for the unusual condition. Difficult cases give readers new insights that hopefully allow them to better treat similar cases in the future. This is particularly important when a relatively uncommon condition (eg, uterine rupture during pregnancy) occurs as a result of a relatively new treatment (eg, uterine artery embolization) or when new or more effective treatment modalities become available for any condition.4 Reading case reports of less common clinical situations serves a purpose similar to pilots’ flight simulators. Experienced pilots do not “fly simulators” to improve their skills at routine takeoffs and landings. Rather, simulator training allows the pilot to review and reinforce the recognition of and appropriate response to uncommon emergencies. If such a situation occurs in real life, the pilot is more likely to respond effectively even if it is the first time he or she has experienced it. Good case reports can prepare clinicians for the unexpected.
410
Hurd
Since 1976, case reports have appeared separately from main journal content, first in a special supplement to Obstetrics & Gynecology sponsored by an advertiser and then later evolving to “Part 2” issues of the journal published twice yearly.5 The advantage of publishing case reports separately is that a large number of cases can be read in a single issue, and these less-scientific reports are less likely to distract readers from the research articles and review articles published in the regular monthly issues. The disadvantages are that publication of individual case reports sometimes is delayed and Journal readers have to make an extra effort to read them. Beginning in January 2015, case reports again will be included in each regular issue of Obstetrics & Gynecology. The number of case reports will be limited to avoid inordinately increasing the page count of the each issue. Efforts will be made to keep case report topics balanced between the obstetrics field and the gynecology field. Only the best of the best will be published, and we will continue to ensure that each case report contains clear clinical teaching points. We hope that the return of case reports to each issue will be of value to Obstetrics & Gynecology readers. REFERENCES 1. Scott JR. In defense of case reports. Obstet Gynecol 2009;114: 413–4. 2. Robinson BL, Liao JB, Adams SF, Randall TC. Vaginal cuff dehiscence after robotic total laparoscopic hysterectomy. Obstet Gynecol 2009;114:369–71. 3. Tonelli MR. The philosophical limits of evidence-based medicine. Acad Med 1998;73:1234–40. 4. Yeaton-Massey A, Loring M, Chetty S, Druzin M. Uterine rupture after uterine artery embolization for symptomatic leiomyomas. Obstet Gynecol 2014;123:418–20. 5. Pitkin RM. The Green Journal history: 50 years on. Washington (DC): American College of Obstetricians and Gynecologists; 2003.
Case Reports in the Era of Evidence-Based Medicine
OBSTETRICS & GYNECOLOGY
