Case report as a challenge in clinical practice and research

by, Prof. Asoc. Dr. Voltisa Lama

Editorial

The clinical case report has a long-standing tradition in the medical literature and despite the recent tendency toward a reduced acceptance of case reports in some high impact journals as more advanced research methods have gained ground, the genre still appears popular. It is a valued part of the different research methods, especially since it complements other approaches (2). Clinical cases provide a very useful tool by which clinicians can share their experience and may be considered as decisive evidence if they are well-designed and accurately presented.

A case report consists most often of one case or even two cases; while the case series report usually consists of three to ten patients. Case reports and case series reports are descriptive studies based on single or multiple observations made during the patient assessment. Case reports describe rare and atypical issues and it is a unique approach to present unusual and uncontrolled observations regarding the symptoms of the patient, the clinical and lab findings, the side effects of medications, the course of illness, complications of interventions, etc. In short, anything that is rare or has never been observed from clinicians previously might be noteworthy for the medical community and ought to be published2.

The clinical case is unique in taking care of the detailed study of the individual patient. A detailed description of the history, examination findings, special investigations, and management are crucial to the interpretation of the case. The case report allows emphasis on the narrative aspect, especially in the field of psychology and psychiatry. The objective is not generalizable knowledge, but an understanding of the meaning and intentionality for an individual or individuals, which is really important in the medical field. Relevant examples are Sigmund Freud’s breakthrough case study of the patient “Anna O”, by which Freud discovered the unconscious root of her disease and how to treat her somatization symptoms, or Hans Asperger’s publication in which he described children with different wired cognitive style, and together with Kanner study of a similar group of children brought to the discovery of what today is called the “autism spectrum disorder”. In the medical field the patient’s symptoms or findings should be described meticulously, making it possible for other medical doctors to detect cases with similar clinical pictures.
There are various advantages and also some disadvantages to the case study approach as a research method. Case reports have proved useful in the identification of adverse and beneficial effects, the recognition of new diseases, unusual forms of common diseases, and the presentation of rare diseases. From a single patient or case series report new hypotheses could be formulated. These hypothesis could then be tested with another type of study that is designed to contest or confirm the hypotheses. Case reports are considered the lowest level of evidence, but they are also the first line of evidence, because they are where new issues and ideas emerge. They can help in the identification of new trends or diseases. Still, the method is unable to deliver quantitative data and there is a lack of ability to generalize, no possibility to establish cause-effect and bias of over-interpretation. The major challenges to case studies are based on generalization, validity and longevity of the case. Case reports should explore and infer, not confirm, deduce, or prove.

The editorial policies of the journal will influence the format of publication. Compared with other study designs case reports provide a lower level of evidence and case reports are less cited, which may adversely affect a journal’s impact factor. We have published in the previous Medicus journals 1-2 cases per issue. Although high-impact journals have reduced the number of case reports and case series published per issue, these types of study continue to have a unique importance in the field of health sciences3, indicating that they still carry weight in the scientific medical literature. The proficiency and judgment that clinicians acquire through clinical experience and clinical practice is reflected in more accurate diagnosis and in their clinical decisions.