Friday, May 30, 2008

Case Reports: Why We Need Them

Case reports get the short end of the stick. In our evidence-based world, we know that the case report is often seen as slightly more useful than an anecdote; we have all seen evidence hierarchies which place the case report low on the "level of evidence" scale. But the importance of a case report cannot be overestimated. Let me demonstrate this by noting the following tale: early in 1981 an initial case report of a young man with a rare form of cancer was printed in a leading medical journal. What was unusual in this case was the presence of Kaposi’s sarcoma, which traditionally had been associated with older, immune-compromised patients. To see this in a young person was certainly noteworthy. That single paper signaled the onset of the today’s AIDS crisis, and led later that year to report in the Lancet detailing this finding in a larger number of individuals (1). All from a single case report.

The point of placing the case report lower on the evidence hierarchy is to recognize that we cannot generalize the findings from a single case to a larger population. To do that, we would need a clinical trial. But that does not mean case reports have no value. From my perspective, it is important for the chiropractic profession to document the full breadth and depth of what it does. It is simply not possible, either financially or logistically, to implement and conduct a clinical trial for every conceivable condition chiropractors treat. But a well-written case report can provide guidance for clinicians grappling with managing conditions that are outside their daily norm. In my former role as journal editor, I spent a significant amount of time doing outreach to the clinical chiropractic community- field practitioners and faculty clinicians- to entice them into considering preparing case reports. As far back as 1991, I reported on my success in doing so (2). Even today, with the huge growth in evidence-based practice, I think a good case report has value, so long as we understand its limitations.

To those in clinical practice, to those who act as our faculty clinicians, the question I have is: have you seen an interesting case? Something that was unusual and therefore educational? It might be an unusual diagnosis not normally seen in a chiropractic setting, or perhaps it was an unusual response to therapy. If so, why not consider writing it up? Let me know and I can help you do so. Give it a shot, why don’t you?

1. Hymes, K.B., Greene, J. B., Marcus, A., et al. Kaposi's sarcoma in homosexual men: A report of eight cases. Lancet 1981;2:598-600
2. Lawrence DJ. Fourteen years of case reports. J Manipulative Physiol Ther 1991;14:447-449

Wednesday, May 28, 2008

Why Write?

For many of us, it has been a long time since we have written anything for other people to read. Yet, in science, the main mode of communication is via the written word, largely through the scientific paper. Like other enterprises, writing takes work and skill, skill that we may not have exercised in some time. As I speak to people and urge them to consider writing, I often hear them tell me that they cannot write well and therefore they do not write at all. But if we follow the dictum that a long journey starts with a single step, we have to start somewhere.

On those occasions where I have the opportunity to speak individually to faculty members about writing, I generally have two comments I make to them. The first is to write about what they are passionate about; that is, write about what interests you and what you wish to share with others. The second is, simply write. Don’t worry about whether it is well written or not; editors and colleagues can help you clean up grammar and spelling. The important thing is to get words down; once they are down, they can be revised. I do believe that there are many people who have written the Great American Novel. In their heads, not on paper.

Writing takes practice. The more you do it, the better you get at it. While I’ve published a fairly decent number of papers during the course of my career, I still had to write my first and submit it for review. I did; it was returned and I was asked to significantly revise that work. At that point, I could have given up and thrown in the towel, but a certain tenacity is necessary, an ability to handle criticism and not give up. Everyone writes papers that end up being revised. It is part of the process.

So let me ask you a question? What are you interested in? What do you have passion about, professionally? Why not share that with your colleagues and with our profession? I hope in this blog series to begin discussing the process of writing for publication. I’ll mix that in with entries addressing the art of teaching. We are all scholars, and together we can move our profession forward.