Table of Contents  
EDITORIAL
Year : 2012  |  Volume : 5  |  Issue : 1  |  Page : 1-3  

From art to science: From case report to evidence based medicine


Department of Community Medicine, Dr. D. Y. Patil Medical College, Pune, Maharashtra, India

Date of Web Publication20-Jun-2012

Correspondence Address:
Amitav Banerjee
Editor in Chief, Department of Community Medicine, Dr. D. Y. Patil Medical College, Pune - 411018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.97496

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How to cite this article:
Banerjee A. From art to science: From case report to evidence based medicine. Med J DY Patil Univ 2012;5:1-3

How to cite this URL:
Banerjee A. From art to science: From case report to evidence based medicine. Med J DY Patil Univ [serial online] 2012 [cited 2024 Mar 29];5:1-3. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2012/5/1/1/97496

A generation or two ago, a quarter of the information a student acquired in medical college got outdated within 10 years. Now change is faster. Presently, half of the information acquired in medical school gets outdated in 5 not 10 years. [1] Advances in diagnoses and treatment are fast paced. Molecular biology and genetics such as mapping of the human genome are evolving so fast that few can keep up with the latest in these fields.

Rapid advances leading to increasing complexity in medical and allied sciences pose a challenge to the medical professional trying to keep his head over water. Making matters more difficult is the professional jargon evolving around newly emerging specialities and super-specialities. In this scenario, there is necessity for a common meeting ground to facilitate balanced patient care. Medical journals to some extent can provide this platform. The specialist medical journals may have limited readership and may not facilitate communication of information among the medical fraternity. Non specialist medical journals may perhaps be a better mode of communication across medical disciplines. Such journals can serve as a road map to navigate our way through the rapidly developing medical field.

Advances in the medical field coupled with conflicting claims led to the evolution of Evidence Based Medicine (EBM) with a common vocabulary and a uniform method of scientific reporting cutting across all medical disciplines. EBM insists that all treatment decisions be based strictly on statistically established facts. Treatment which has not been established by rigorous statistical hypotheses testing is looked down upon. Sufficient body of data has to be generated first preferably from clinical trials. This scientific re-orientation of the ancient practice of medicine which was traditionally an art is difficult for most doctors who hitherto have been dictated by experience and instinct. Doctors in clinical practice, tend to be fascinated by the rare and unique which are reported in the form of case reports and short communications. The more rigorous workup for an original article based on principles of EBM does not attract many practicing clinicians.

Some people question whether the present day pre-occupation with EBM and the exclusion of the "art" of medicine can always resolve the doctor's dilemma. Proponents of EBM are optimistic and are reluctant to settle for anything less. Rather they ridicule alternatives to EBM. [2] In their repertoire; case reports and personal experiences of experts are low down in hierarchy of medical evidence. Others have reservations whether EBM can resolve all medical controversies. [3] They caution that EBM has limitations when the physician needs to think outside the box, when symptoms are vague and test results are equivocal. Groopman [3] argues that, "...rigid reliance on evidence-based medicine risks having the doctor choose care passively, solely by the numbers. Statistics cannot substitute for the human being before you; statistics embody averages, not individuals. Numbers can only complement a physician's personal experience with a drug or a procedure, as well as his knowledge whether a best therapy from a clinical trial fits a patient's needs and values." He laments that the next generation of doctors is being conditioned to function like a well-programmed computer.

Both extreme views have their limitations. The way forward should be not to rely exclusively on either point of view. The wise doctor should use the science of EBM for the routine cases, and know when to fall back on the traditional art of medicine when dealing with atypical cases.

One of the fallouts of the paradigm shift precipitated by the ascendency of EBM was the trend of published articles in mainstream journals. Medical journals particularly those aspiring for a high impact factor shunned case reports in favour of clinical trials. Case reports became the least distinguished section of a medical journal. [4] The more prestigious the journal the fewer the case reports it published.

One should appreciate that the "gold standard" of EBM i.e. the randomized controlled trials are resource intensive both in time and money; thus a difficult proposition for developing countries. They also raise many ethical concerns in poor countries.

In developing countries, with their burden of communicable and rapidly emerging non-communicable diseases with occasional uncommon presentations case reports are good teaching material. Well written case reports can contribute to medical education. They are one of the conventional techniques of teaching clinical medicine. Familiarization with case reports and case series can add up to valuable medical wisdom. They are also faster to publish, and can be submitted by busy clinicians with limited resources to conduct large scale research. [5] They also make interesting reading for physicians from other specialties, and therefore well suited for a non specialist medical journal. Occasionally, they may be the first step to a greater discovery.

There are many examples where the unique and unusual in form of case reports and case series have been the starting point of major new discoveries, which were later refined with more rigorous studies. In 1978 a case report was published in the Lancet [6] describing one case and mentioning six other children with signs and symptoms now recognized as the toxic shock syndrome. The report made no mention of the menstrual status of any of the teenagers and failed to mention the gender of all the cases. If one reads this case report now, in hindsight, one would judge it critically and say it is sketchy. In spite of its limitation, it paved the way for more detailed studies which established the link between tampons used during menstruation and toxic shock syndrome. [7] Similarly, in 1981, the American Journal of Dermatopathology published a very short case report with a very nondescript title. [8] These series of case reports raised questions and suggested the hypotheses of an infectious origin, which later turned out to be the initial cases of a condition later identified as AIDS. [7]

Many practitioners of conventional medicine think that complementary and alternative systems of medicine co-existing with conventional medicine make strange bedfellows. Complementary and alternative medicine refers to a group of medical and health care systems, practices and products that are not considered to be part of conventional medicine. [9] It encompasses a vast and ever changing range of activities, from well established physical therapies such as osteopathy, alternative medicine such as Homeopathy and Ayurveda which are gradually adopting the methods of EBM and in the other extreme spiritual measures such as prayer and meditation for health. In recent times there is popular and political demand to integrate complementary and alternative medicine at the level of resource allocation, service design, national health policy, clinical practice, education and research. Historically, patients using both types of therapy have often experienced conflicting and confusing advice and value judgments, poor or absent communication between practitioners, and even hostilities or ridicule. They often withhold information from their physician, a potentially hazardous and undesirable phenomenon. Holistic health care approach as envisaged in the National Health Policy aims to understand and remove the barriers that create such dilemmas for patients. It aims to let them exercise their preference for systems of medicine in an open environment of good communication, respect, and regard to autonomy, efficacy and hazards.

Prejudice leads to biased views towards other systems of medicine, when an objective evaluation of all systems of medicine is indicated. If we (including the editor of this journal) have little faith in systems of medicine other than ours, extra-special care should be taken to ensure objectivity in the interpretation of papers from researchers in alternative systems of medicine. When appraising them we should 'bend over backwards' and consciously set out to seek information to the credit of these other perspectives. Regrettably, not all readers (and editors) from mainstream medicine make the effort. To maintain "a fine balance," between all systems of medicine, we would welcome papers from practitioners of Complementary and Alternative Systems of Medicine.

Modern education is not just about acquiring a degree or building loads of self confidence in one's own time trusted methods; it is about experimenting with new ideas and challenging the old ones (and in the context of alternative medicine, to challenge new ideas and experiment with old ones!!). A modern university is not just huge lecture halls and hi-tech labs; it is a place that can take young minds to the frontiers of knowledge and imagination resulting in greater creativity. A scientific journal provides on outlet for such ventures. The bottom line is we must always seek - the search is never complete. As summed up by the French Nobel Laureate Andre Gide, "Believe those who are seeking the truth. Doubt those who find it."

 
  References Top

1.Last JM. Public Health and human ecology. 2 nd ed. London, UK: Prentice Hall International Inc.; 1998. p. 428.  Back to cited text no. 1
    
2.Issacs D, Fitzgerald D. Seven alternatives to evidence-based medicine. BMJ 1999:319:1618.  Back to cited text no. 2
    
3.Groopman J. How Doctors think. Reprinted. Delhi, India: Byword Books Private Limited; 2011. p. 5-6.  Back to cited text no. 3
    
4.Morgan PP. Why case reports? Can Med Assoc J 1985:133:353.  Back to cited text no. 4
    
5.Yitschaky O, Yitschaky M, Zadik Y. Case report on trial: Do you, Doctor, swear to tell the truth, the whole truth and nothing but the truth? J Med Case Rep 2011:5:179.  Back to cited text no. 5
    
6.Todd J, Fishaut M, Kapral F, Welch T. Toxic shock syndrome associated with phage group - 1 Staphylococci. Lancet 1978:2:1116-8.  Back to cited text no. 6
    
7.Morris BA. The importance of case reports. CMAJ 1989:141:875-6.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Gottlieb GJ, Ragoz A, Vogel JV. A preliminary communication on extensively disseminated Kaposi's sarcoma in young homosexual men. Am J Dermatopathol 1981:3:112-4.  Back to cited text no. 8
    
9.Cumming AD, Noble SI. Good Medical Practice. In: Colledge NR, Walker BR, Ralston SH, editors. Davidson's Principles and Practice of Medicine. 21 st ed. Edinburg: Churchill Livingstone Elsevier; 2010. p. 1-16.  Back to cited text no. 9
    



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