|Year : 2015 | Volume
| Issue : 6 | Page : 697-699
Case reports: The ideal weaning food: Food for thought
Department of Community Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Web Publication||19-Nov-2015|
Department of Community Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Banerjee A. Case reports: The ideal weaning food: Food for thought. Med J DY Patil Univ 2015;8:697-9
The Chinese philosopher Lao Tzu is believed to have said that a journey of a thousand miles begins with a single step.  Similarly, every research on human subjects starts with a single case. The case report is the most fundamental type of descriptive study carried out by careful and detailed report by the clinician of the profile of a single patient. Sir William Osler stated, "each case has its lesson - A lesson which may be but is not always learned." Case presentation and discussion as done during ward rounds and clinical meetings laid the foundation of modern medical education.  They also gave rise to new ideas and helped detect new diseases and treatments. , They continue to play a role in new discoveries.
Busy clinicians tend to develop inertia, not necessarily toward their clinical work but toward academic writing. The term "couch potatoes" has been adapted to "office potatoes" to refer to clinicians who devote their time to their patients and then go home.  They may not have the energy and enthusiasm left to contribute to the medical literature. After a busy day's work attending outpatients, emergencies, or performing surgeries, the "spirit may we willing but the flesh may be weak." Against this background, a simple way to contribute to the medical literature is to write and publish case reports. The case report can describe the different aspects of the patient's condition such as history, physical examination, social aspects, and follow-up. 
Case reports not only has an educational role but has contributed to the advancement of medical knowledge in many instances emphasizing the role of serendipity in research. A few examples will put the role of chance observations in proper perspective in advancing knowledge and occasionally bringing about a paradigm shift. A case report which may seem insignificant when first reported may lead to a breakthrough by other researchers subsequently following up the issues raised. Few examples of case report bringing about a change in treatment and prevention paradigms will illustrate this point.
One of the anecdotal accounts mentions that a tribal in South America suffering from malaria high in a jungle in the Andes, accidentally ingested water contaminated with cinchona which grew nearby. His fever miraculously disappeared. Tribal people did not have medical journals in which this discovery could have been published as a case report. Among them such anecdotes spread by the word of mouth. Local people of the region started using the bark of cinchona to treat malaria.  Almost 400 years after the discovery of its antimalarial properties, it remains an important option in the treatment of malaria.
Another historical example of the power of the "humble case report" is Edward Jenner's discovery of vaccination against smallpox. He had anecdotal information that milkmaids who contracted cowpox never contacted smallpox.  To verify this observation, Jenner took samples from the open cowpox lesions on the hands of milkmaid Sarah Nelmes and inoculated 8-year-old James Phipps with pus extracted from the lesions of cowpox. The boy developed a mild fever and few lesions which were self-limiting. A few months later the boy was injected with secretions from smallpox lesions. The boy did not develop smallpox. This "case report" heralded the era of modern vaccination. 
In more recent times, the journey of amantadine from fighting flu to treating Parkinson's disease (PD) is interesting. Amantadine was originally introduced and utilized as an antiviral agent. A single patient who was taking the drug for flu noticed relief in her PD symptoms. This observation from a single case report sparked an interest the drug as a therapeutic agent for PD, which was established by subsequent research. 
The case report developed strong roots until the first half of the 20 th century. With the ascendency of evidence-based medicine (EBM), the case report gradually got uprooted as editors preferred to publish results of randomized controlled trials (RCTs) and showed less enthusiasm for case reports.  To some extent the practice of shunning case reports is motivated by a desire to play the system to enhance the journal impact factor. Case reports are cited less frequently compared to other types of manuscripts. However, when calculating the journal impact factor they are included in the denominator. This adversely affects the impact factor of a journal which publishes a large number of case reports. One can debate whether this augurs well for science and new discoveries.
Different types of studies serve different purposes. For confirmation of the hypothesis, RCTs are at the top of the hierarchy in the pecking order of EBM. However, what is overlooked that before a proposition or hypothesis is confirmed it has to be first generated. For true novelty which can drive a paradigm shift in medical knowledge, that is, generating new research questions, new hypotheses, or new ideas, the batting order is reversed. For novelty purposes, case reports and case series occupy the top of the hierarchy. Observation of few cases and case series at first which generates and then puts the hypothesis on a firmer footing which then can be confirmed by more robust study designs. Without the starting point of new ideas, that is, the simple case report, all advances in medicine would be adversely affected. Even in the age of EBM, case reports if viewed from this larger and chronological perspective continue to provide the spark for generating new ideas.  Accumulation of case reports may lead to the acceptance of a new technique, generation of a new hypothesis, recognition of a complication, and sometimes how to prevent the complication.  An appropriate example is the early recognition of the HIV/AIDS pandemic which started as reporting of a few case reports of unusual occurrences of rare cancers and rare infections in young men. 
Case reports also play an important role in pharmacovigilance. With the introduction of newer drugs and interventions, case reports are the only means by which an adverse event of a new therapy or intervention can come to notice. 
Against the above backdrop, the recent Medical Council of India Regulations  and subsequent corrigendum to it, stipulating that case reports will not be counted as publication for medical faculty in teaching institution needs to be reconsidered if one wants to promote new ideas. The embargo on case reports as publication also overlooks the ground realities of academic research in India.
Major limitations are lack of adequate resources for research. This includes trained faculty, money, and time. As already brought out at the beginning of the editorial clinicians are very busy people. Case reports are their forte as they evolve from their day to day practice. Research starts with observation. Measurement follows later. New graduates and novice researchers have been fed passively on textbook knowledge. As far as research is concerned they are like newborn exclusively nourished on passive immunity and breast milk. Just as infants are gradually introduced to solid foods by the way of weaning foods, novice researchers should ideally start with case reports before embarking on original articles which require lot of commitments in time and resources which are scarce in Indian Universities.
Not giving credit for case reports is a retrograde step which would stifle original ideas and new discoveries. We will be providing sweatshops for large trials sponsored by global agencies with their own research agendas. Alternatively, in a desperation to publish original articles students and faculty would be tempted to deviate from research integrity as brought out in an earlier editorial.  An honest case report is any day better than an original article with compromised integrity.
It is hoped that the concerned authorities do give some credit for case reports. They may consider giving half a point for a case report as compared to a full point for an original article. This will ensure steady publications of new and interesting case reports which once in a while may contribute greatly to advancement in medical knowledge as substantiated by the history of medicine. Cutting off the supply of new ideas does not augur well for creativity. Doing away with the weaning food of our novice researchers will lead to diarrhea of poor original studies most of which will be published in the "predatory journals"  leading to academic malnourishment.
| References|| |
Fletcher RH, Fletcher SW, Wagner EH, editors. Studying cases. In: Clinical Epidemiology: The Essentials. 3 rd
ed. Baltimore: Williams and Wilkin; 1996. p. 208-27.
Van der Meer JW. Should we do away with case reports? Neth J Med 2002;60:161.
Vandenbroucke JP. In defense of case reports and case series. Ann Intern Med 2001;134:330-4.
Merritt L. Case reports: An important contribution to chiropractic literature. J Can Chiropr Assoc 2007;51:72-4.
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.
Achan J, Talisuna AO, Erhart A, Yeka A, Tibenderana JK, Baliraine FN, et al.
Quinine, an old anti-malarial drug in a modern world: Role in the treatment of malaria. Malar J 2011;10:144.
Willis NJ. Edward Jenner and the eradication of smallpox. Scott Med J 1997;42:118-21.
Hubsher G, Haider M, Okun MS. Amantadine: The journey from fighting flu to treating Parkinson disease. Neurology 2012;78:1096-9.
Nissen T, Wynn R. The clinical case report: A review of its merits and limitations. BMC Res Notes 2014;7:264.
Vandenbroucke JP. Case reports in an evidence-based world. J R Soc Med 1999;92:159-63.
Shyam AK, Shetty GM. Editorial. Case reports and evidence-based medicine: Redefining the apex of the triangle. J Orthop Case Reports 2012;2:1-2.
Centers for Disease Control (CDC). Kaposi′s sarcoma and Pneumocystis pneumonia among homosexual men - New York City and California. MMWR Morb Mortal Wkly Rep 1981;30:305-8.
Arnaiz JA, Carné X, Riba N, Codina C, Ribas J, Trilla A. The use of evidence in pharmacovigilance. Case reports as the reference source for drug withdrawals. Eur J Clin Pharmacol 2001;57:89-91.
Banerjee A. Ethics in medical research: The difficulty of being good. Med J DY Patil Univ 2015;8:421-4.
Butler D. Investigating journals: The dark side of publishing. Nature 2013;495:433-5.