Commentary
About case reports and the perverse application of reasonable principles Mauricio Goihman-Yahr, MD, PhD
Vargas School of Medicine, Central University of Venezuela, Caracas, Venezuela Correspondence Mauricio Goihman-Yahr, MD, PHD, Professor of Immunology and Dermatology Vargas School of Medicine, Central University of Venezuela, Caracas, Venezuela E-mail: [email protected] Conflicts of interest: None.
Introduction The case report is the most ancient and most used form of medical communication. It may have started with mothers comparing notes about their respective children’s ailments, or healers telling one another how they dealt with demons of disease. Hippocrates’ “Aphorisms” are basically condensed and integrated case reports. When physicians talk to each other, often the most common start of a conversation is, “By the way, I had a patient some time ago that . . . .” Medical journals in general, and particularly dermatology journals, were filled with case reports. The case reports were presented as either individual papers or condensed with comments on the “Societies’ Transactions” or “Proceedings.” Nowadays, while case reports continue to be written and sent for publication, they are increasingly rejected or exiled to the internet while other papers are still printed – why is this so? The perverse application of reasonable principles It is reasonable that to evaluate the worth of a given candidate for an appointment or promotion, his curriculum vitae should be analyzed. Publications are an important part of the work of a physician, particularly if this person works in an academic environment. Currently, it is easy to quantitate the number of papers written by an individual and to obtain some information ª 2015 The International Society of Dermatology
about the worth of the journals in which these papers were published. For that, one might determine whether the journal is locally or internationally known as well as look up the impact factor of the journal (more on that below). In addition, determination of whether the candidate is a senior or junior author in the papers is considered. Next, one may easily devise some kind of simple equation or index by means of which the evaluators may obtain a numerical value for each candidate, and compare the values of the aspiring persons when, lo and behold the choice is easily made and, seemingly, in a fair and objective manner. This is far easier than to evaluate the abilities of an individual as a clinician or teacher and as a human being. It is also infinitely easier than to determine the actual worth of the papers that the person may have written. As a result, everybody gets into the race to publish, and the seemingly easiest paper to write is a case report; in particular, when the case itself is submerged in an extensive and wordy review of the literature including, if feasible, papers by the author himself (icing on the cake). So, where is the perversity? It rests on the use of impact factors and sheer number of publications to a task that they were not fit to perform and to give superficially analyzed numerical values, a weight that they do not have. Reaction of the journal Clinical journals receive too many case reports. Most of them are not that bad, they have a story to tell. Yet, this International Journal of Dermatology 2016, 55, 117–119
117
118
Commentary
Case reports misusing reasonable principles
story should be told in meetings, or posters, not in journal publications. Referees find it difficult to decide what to reject or accept. Differences between respective qualities of manuscripts are slight. Currently, editors do not like to publish case reports. Why? While they are read (and the better ones with gusto), most of them are not cited, precisely because (particularly in dermatology) they dwell on detail or rarity or minor differences from known clinical pictures. If papers are not cited . . . catastrophe and the impact factor of the journal goes down. Nothing worse could happen. It is much better to publish a clinical trial of a minor variant of a well-known therapeutic agent. It will certainly be found significantly more effective than . . . the placebo. Such a trial funded directly or indirectly by a manufacturer will be, in all likelihood, profusely cited. Another variant is some kind of review carried out via computer by an industrious, computer-savvy medical student or young resident. A famed professor or researcher will polish the paper, improve its overall make-up, and provide, here and there, some words of wisdom. This kind of review will add little or nothing new and will give little or no personal opinions. It will give out data that the reader may use, as is his wont. However, again it will be cited and for a long time – reviews never die . . . so, so much the better. In summary, out with the case report, in with the neutral therapeutic assay or the sterile meaningless aseptic review. The true place of case reports in medical literature The observation of an individual or several related cases, analyzed by that powerful tool called the brain, has been, is, and will be a major component of clinical and basic medicine. Several outstanding publications have kept case reports in their roster, be it in a constant fashion or from time to time. This will be appreciated from examples that I will include ahead. 1 Atanasovski and Watson1 described a case in the Journal of the American Academy of Dermatology, where a man had metastatic melanoma in the mesentery and omentum. A positron emission tomography scan showed increased uptake in multiple cutaneous and subcutaneous areas in the neck, shoulders, and chest. It turned out that these were not due to metastatic melanomas but to lesions of cystic acne. 2 Thomas et al.2 reported an index case and three other cases of Mycobacterium ulcerans infection, imported from Australia to Missouri. There is an excellent analysis, with good clinical pictures and an excellent table that summarizes an update of therapy. This was published in Emerging Infectious Diseases. International Journal of Dermatology 2016, 55, 117–119
Goihman-Yahr
3 These are three independent case reports in The Lancet. Euser et al.3 reported a case of Legionnaire’s disease in an 81-year-old man. Investigation of sources finally showed that the source came from a car wash, where the patient had washed his vehicle using a hose. This concise paper had five references, no illustrations, and was one page long. Migliore et al.4 reported a case of flank pain due to the slipping rib syndrome. There was sudden lower chest pain. All paraclinical exams were negative or normal, and a psychiatric consultation was even sought. Finally, the diagnosis was found by using a clinical maneuver, where pain was reproduced by pressing the lower chest. Later, surgery confirmed the diagnosis. The paper was one page long, had one photograph, and four references. Just to close this short series of Lancet cases, Islamian et al.5 reported a case of chronic subdural hematoma secondary to head banging. Despite its name, head banging does not involve direct trauma to the head, but forceful extension and flexion of the head in a form of dancing. The paper had only one page, a picture of a computed tomography scan and five references. 4 While certainly not short, one of the most fundamental case reports in medical history was that of BeguezCesar, in 1943.6 The author described cases of what he called malignant familial chronic neutropenia with atypical granulations in leukocytes. The clinical and microscopic description of this disease, now improperly known as Chediak–Higashi syndrome, opened the door to the concept of lysosomal diseases. 5 Ramírez-Duque et al.7 reported a cluster of many cases of this condition in an isolated area of Venezuela, where intermarriage was common. Local people had been aware of the condition and called the little patients “old ones” because of their silvery hair. What can be distilled from the analysis of such reports? 1 They are the result of careful observation and judicious use of paraclinical tests as they are available. 2 The observation is done for the required amount of time; it can be short, it is never hurried or superficial. 3 There is an honest effort to interpret the experiment of nature, which is what makes a case report. 4 There is always a teaching, and the findings are never obvious. They require effort and creative ability, and sometimes outstanding creative ability. 5 The writing is mostly clear, and the length of the paper is never excessive. Conclusions What should journals do? Continue publishing case reports from wherever they come, but they must be conª 2015 The International Society of Dermatology
Goihman-Yahr
cise, in text, illustrations, and references. There must be a significant teaching, an important new finding. A good case report should always leave the reader thinking about it and learning. Minutiae have a place but not in single published case reports. Finally, there should be a movement to stop the perverse use of otherwise reasonable indexes or parameters. History shows that aberrations in the use of information are always harmful and many times lead to abolishing the employment of interesting data. The abuse of information about ethnic groups, religion, sexual orientation, and such has led to erasing such information from, say, identity papers or many questionnaires. It would have been much better if the use given to perfectly valid information would not have been perverted to lead to blatant discrimination and even genocide. I am not alone in this opinion; on a slightly different note, the Editor of Science, Marcia Mc Nutt, advocated for a change stressing that, “it is time to remedy a flawed bibliometric-based assessment for young scientists.”8 In my opinion, there are two key concepts here, “flawed” and “bibliometric-based assessment.”
Case reports misusing reasonable principles
2
3
4 5
6
7
8
Commentary
computed tomography scan. J Am Acad Dermatol 2013; 69: 480. Thomas BS, Bailey TC, Bhatnagar J, et al. Mycobacterium ulcerans infection imported from Australia to Missouri, USA, 2012. Emerg Infect Dis 2014; 20: 1876–1879. Euser SM, de Jong S, Bruin JP, et al. Legionnaires’ disease associated with a car wash installation. Lancet 2013; 382: 2114. Migliore M, Signorelli M, Caltabiano R, et al. Flank pain caused by slipping rib syndrome. Lancet 2014; 383: 844. Islamian AP, Polemikos M, Krauss JK. Chronic subdural haematoma secondary to headbanging. Lancet 2014; 384: 102. Beguez-Cesar A. Neutropenia cr onica maligna familiar con granulaciones atıpicas de los leucocitos [Chronic malignant familial neutropenia with atypical granulations of leukocytes]. Bol Soc Cubana Pediatr 1943; 15: 900–922. Ramírez-Duque P, Arends T, Merino F. Chediak-Higashi syndrome: description of a cluster in a Venezuelan-Andean isolated region. J Med 1982; 13: 431–451. Mc Nutt M. The measure of research merit (Editorial). Science 2014; 346: 1155.
References 1 Atanasovski M, Watson AC. Acne masquerading as malignant melanoma on positron emission tomography-
ª 2015 The International Society of Dermatology
International Journal of Dermatology 2016, 55, 117–119
119
About case reports and the perverse application of reasonable principles Mauricio Goihman-Yahr, MD, PhD
Vargas School of Medicine, Central University of Venezuela, Caracas, Venezuela Correspondence Mauricio Goihman-Yahr, MD, PHD, Professor of Immunology and Dermatology Vargas School of Medicine, Central University of Venezuela, Caracas, Venezuela E-mail: [email protected] Conflicts of interest: None.
Introduction The case report is the most ancient and most used form of medical communication. It may have started with mothers comparing notes about their respective children’s ailments, or healers telling one another how they dealt with demons of disease. Hippocrates’ “Aphorisms” are basically condensed and integrated case reports. When physicians talk to each other, often the most common start of a conversation is, “By the way, I had a patient some time ago that . . . .” Medical journals in general, and particularly dermatology journals, were filled with case reports. The case reports were presented as either individual papers or condensed with comments on the “Societies’ Transactions” or “Proceedings.” Nowadays, while case reports continue to be written and sent for publication, they are increasingly rejected or exiled to the internet while other papers are still printed – why is this so? The perverse application of reasonable principles It is reasonable that to evaluate the worth of a given candidate for an appointment or promotion, his curriculum vitae should be analyzed. Publications are an important part of the work of a physician, particularly if this person works in an academic environment. Currently, it is easy to quantitate the number of papers written by an individual and to obtain some information ª 2015 The International Society of Dermatology
about the worth of the journals in which these papers were published. For that, one might determine whether the journal is locally or internationally known as well as look up the impact factor of the journal (more on that below). In addition, determination of whether the candidate is a senior or junior author in the papers is considered. Next, one may easily devise some kind of simple equation or index by means of which the evaluators may obtain a numerical value for each candidate, and compare the values of the aspiring persons when, lo and behold the choice is easily made and, seemingly, in a fair and objective manner. This is far easier than to evaluate the abilities of an individual as a clinician or teacher and as a human being. It is also infinitely easier than to determine the actual worth of the papers that the person may have written. As a result, everybody gets into the race to publish, and the seemingly easiest paper to write is a case report; in particular, when the case itself is submerged in an extensive and wordy review of the literature including, if feasible, papers by the author himself (icing on the cake). So, where is the perversity? It rests on the use of impact factors and sheer number of publications to a task that they were not fit to perform and to give superficially analyzed numerical values, a weight that they do not have. Reaction of the journal Clinical journals receive too many case reports. Most of them are not that bad, they have a story to tell. Yet, this International Journal of Dermatology 2016, 55, 117–119
117
118
Commentary
Case reports misusing reasonable principles
story should be told in meetings, or posters, not in journal publications. Referees find it difficult to decide what to reject or accept. Differences between respective qualities of manuscripts are slight. Currently, editors do not like to publish case reports. Why? While they are read (and the better ones with gusto), most of them are not cited, precisely because (particularly in dermatology) they dwell on detail or rarity or minor differences from known clinical pictures. If papers are not cited . . . catastrophe and the impact factor of the journal goes down. Nothing worse could happen. It is much better to publish a clinical trial of a minor variant of a well-known therapeutic agent. It will certainly be found significantly more effective than . . . the placebo. Such a trial funded directly or indirectly by a manufacturer will be, in all likelihood, profusely cited. Another variant is some kind of review carried out via computer by an industrious, computer-savvy medical student or young resident. A famed professor or researcher will polish the paper, improve its overall make-up, and provide, here and there, some words of wisdom. This kind of review will add little or nothing new and will give little or no personal opinions. It will give out data that the reader may use, as is his wont. However, again it will be cited and for a long time – reviews never die . . . so, so much the better. In summary, out with the case report, in with the neutral therapeutic assay or the sterile meaningless aseptic review. The true place of case reports in medical literature The observation of an individual or several related cases, analyzed by that powerful tool called the brain, has been, is, and will be a major component of clinical and basic medicine. Several outstanding publications have kept case reports in their roster, be it in a constant fashion or from time to time. This will be appreciated from examples that I will include ahead. 1 Atanasovski and Watson1 described a case in the Journal of the American Academy of Dermatology, where a man had metastatic melanoma in the mesentery and omentum. A positron emission tomography scan showed increased uptake in multiple cutaneous and subcutaneous areas in the neck, shoulders, and chest. It turned out that these were not due to metastatic melanomas but to lesions of cystic acne. 2 Thomas et al.2 reported an index case and three other cases of Mycobacterium ulcerans infection, imported from Australia to Missouri. There is an excellent analysis, with good clinical pictures and an excellent table that summarizes an update of therapy. This was published in Emerging Infectious Diseases. International Journal of Dermatology 2016, 55, 117–119
Goihman-Yahr
3 These are three independent case reports in The Lancet. Euser et al.3 reported a case of Legionnaire’s disease in an 81-year-old man. Investigation of sources finally showed that the source came from a car wash, where the patient had washed his vehicle using a hose. This concise paper had five references, no illustrations, and was one page long. Migliore et al.4 reported a case of flank pain due to the slipping rib syndrome. There was sudden lower chest pain. All paraclinical exams were negative or normal, and a psychiatric consultation was even sought. Finally, the diagnosis was found by using a clinical maneuver, where pain was reproduced by pressing the lower chest. Later, surgery confirmed the diagnosis. The paper was one page long, had one photograph, and four references. Just to close this short series of Lancet cases, Islamian et al.5 reported a case of chronic subdural hematoma secondary to head banging. Despite its name, head banging does not involve direct trauma to the head, but forceful extension and flexion of the head in a form of dancing. The paper had only one page, a picture of a computed tomography scan and five references. 4 While certainly not short, one of the most fundamental case reports in medical history was that of BeguezCesar, in 1943.6 The author described cases of what he called malignant familial chronic neutropenia with atypical granulations in leukocytes. The clinical and microscopic description of this disease, now improperly known as Chediak–Higashi syndrome, opened the door to the concept of lysosomal diseases. 5 Ramírez-Duque et al.7 reported a cluster of many cases of this condition in an isolated area of Venezuela, where intermarriage was common. Local people had been aware of the condition and called the little patients “old ones” because of their silvery hair. What can be distilled from the analysis of such reports? 1 They are the result of careful observation and judicious use of paraclinical tests as they are available. 2 The observation is done for the required amount of time; it can be short, it is never hurried or superficial. 3 There is an honest effort to interpret the experiment of nature, which is what makes a case report. 4 There is always a teaching, and the findings are never obvious. They require effort and creative ability, and sometimes outstanding creative ability. 5 The writing is mostly clear, and the length of the paper is never excessive. Conclusions What should journals do? Continue publishing case reports from wherever they come, but they must be conª 2015 The International Society of Dermatology
Goihman-Yahr
cise, in text, illustrations, and references. There must be a significant teaching, an important new finding. A good case report should always leave the reader thinking about it and learning. Minutiae have a place but not in single published case reports. Finally, there should be a movement to stop the perverse use of otherwise reasonable indexes or parameters. History shows that aberrations in the use of information are always harmful and many times lead to abolishing the employment of interesting data. The abuse of information about ethnic groups, religion, sexual orientation, and such has led to erasing such information from, say, identity papers or many questionnaires. It would have been much better if the use given to perfectly valid information would not have been perverted to lead to blatant discrimination and even genocide. I am not alone in this opinion; on a slightly different note, the Editor of Science, Marcia Mc Nutt, advocated for a change stressing that, “it is time to remedy a flawed bibliometric-based assessment for young scientists.”8 In my opinion, there are two key concepts here, “flawed” and “bibliometric-based assessment.”
Case reports misusing reasonable principles
2
3
4 5
6
7
8
Commentary
computed tomography scan. J Am Acad Dermatol 2013; 69: 480. Thomas BS, Bailey TC, Bhatnagar J, et al. Mycobacterium ulcerans infection imported from Australia to Missouri, USA, 2012. Emerg Infect Dis 2014; 20: 1876–1879. Euser SM, de Jong S, Bruin JP, et al. Legionnaires’ disease associated with a car wash installation. Lancet 2013; 382: 2114. Migliore M, Signorelli M, Caltabiano R, et al. Flank pain caused by slipping rib syndrome. Lancet 2014; 383: 844. Islamian AP, Polemikos M, Krauss JK. Chronic subdural haematoma secondary to headbanging. Lancet 2014; 384: 102. Beguez-Cesar A. Neutropenia cr onica maligna familiar con granulaciones atıpicas de los leucocitos [Chronic malignant familial neutropenia with atypical granulations of leukocytes]. Bol Soc Cubana Pediatr 1943; 15: 900–922. Ramírez-Duque P, Arends T, Merino F. Chediak-Higashi syndrome: description of a cluster in a Venezuelan-Andean isolated region. J Med 1982; 13: 431–451. Mc Nutt M. The measure of research merit (Editorial). Science 2014; 346: 1155.
References 1 Atanasovski M, Watson AC. Acne masquerading as malignant melanoma on positron emission tomography-
ª 2015 The International Society of Dermatology
International Journal of Dermatology 2016, 55, 117–119
119
