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The Demise of the Case Report

¹ Both authors: Department of Radiology, Adelaide & Meath Hospital, incorporating The National Children's Hospital, Tallaght Hospital, Tallaght, Dublin 24, Ireland.

Received December 30, 2006; accepted after revision March 28, 2007.

 
Address correspondence to W. C. Torreggiani.

WEB This is a Web exclusive article.

Keywords: case reports • education • medical publishing

Introduction

Top Introduction The Case for Rejecting... The Case for Accepting...

 
In November 2005, a key editorial decision was made by the American Journal of Roentgenology (AJR) that case reports would no longer be accepted for submission to the journal [1]. This change in policy was made following the guidance of the Executive Council of the American Roentgen Ray Society and was prompted by a report of the Publications Committee.

One of the reasons for the decision to no longer accept case reports is that there was a huge increase in the number of manuscripts submitted to AJR after the opening of the portal for Web-based online manuscript submission. To counteract the potential buildup of a backlog of case reports, stricter criteria for publication were adopted. In addition, case reports were generally deemed not to have as much merit as original research and were therefore preferentially sacrificed to allow more space to publish full articles.

This policy is not unique to the AJR; in fact, no longer publishing case reports has become an adopted stance by many American, Asian, and European journals both within and without the field of radiology. Although this decision carries significant merit, there are some disadvantages to this policy. It provided a timely and useful exercise to discuss the case for and the case against the rejection of case reports.

The Case for Rejecting Case Reports

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With the widespread adoption of online submissions, many journals have been inundated by a huge number of case reports. Case reports are generally quick to write and are often written by eager residents or medical students keen to have their work appear in a peer-reviewed publication. We are all familiar with the CT or MRI readout on which the staff radiologist announces that the case being reported is a "great case" and points to the most eager resident that he or she should write a case report to submit to journals. Many of these case reports carry little merit apart from the fact that the cases are interesting or rare.

In the past, case reports demanded significantly more effort to write, so only unique cases tended to be described. However, with the widespread availability of digital images and online access to MEDLINE and other searchable and downloadable databases, writing a case report has become considerably easier. In addition, submitting manuscripts to journals is now easier and cheaper because of the widespread adoption of online submission. If a case report is rejected from one journal, it is relatively effortless to forward it to another online journal. As a result, online journals have found it difficult to cope with the dramatic rise in online submissions. Of the cases reports that are submitted, only a small percentage describe a case of sufficient merit to warrant publication. Thus, the increase in the number of submissions has led to a large increase in the editorial workload for each journal with a relatively small return.

Many case reports are submitted on the basis of a unique association of two disease processes—for example, a patient with known neurofibromatosis presents with a rare bone tumor. Does this case represent a chance finding of two disease processes or does it truly represent a newly discovered association? This distinction cannot be made on the basis of a single case and requires a more scientific analysis of the disease processes.

Another common problem with case reports is the claim of many authors that theirs is the first case report to describe a specific disease. This assertion is usually based on a literature search done on MEDLINE. However, it is virtually impossible to be certain of a "first" on the basis of a literature search alone. It is not rare for publication of a case report in which authors claim their case is the "first" to be followed by a letter to the editor by another group of authors citing a previously published case. To attempt to circumvent this problem, authors often use a safety play on words such as "To the best of our knowledge, this is the first case of...." The addition of this phrase covers the likelihood that a previous case was not found on their literature search. However, such uncertainty does not provide a scientifically sound basis for a journal's content and is an editorial nightmare.

When all of these factors are considered, it makes sense for a journal's editorial body to dismiss case reports as a type of article in their journal: It obviates extensive editorial review and assessment and allows room for more meaningful articles. Based on this assessment, AJR leaders made the correct decision in 2005 when they decided to stop accepting case reports for publication.

The Case for Accepting Case Reports

Top Introduction The Case for Rejecting... The Case for Accepting...

 
Even with the demise of the conventional case report, other routes by which the potential academic radiologist may get started still exist. Some journals include sections such as "Signs in Imaging," "Case of the Month," or "Radiologic-Pathologic Correlation" that allow authors to submit articles in a format similar to that of a case report. AJR has had a section titled "On the AJR Digital Viewbox" that allows authors to present short cases that are of unusual interest or are a rarity. Other journals may have a quiz section, such as the "Interpretation Corner" in European Radiology and "Diagnosis Please" in Radiology, again allowing an entrance point to the novel academic. Writing such articles helps authors develop skills that allow them to expand their experience with paper writing and hopefully to progress to writing full papers.

The publication of a case report is often the first step for many potential academics. Writing a cases report may stimulate academics to realize the goal of seeing their writing in print and may encourage them to greater things. A case report is a relatively easy way to produce a paper. For junior residents and medical students passing through a radiology rotation, it is often difficult to be in the rotation long enough to fully participate in a research paper, which may require months of background work and analysis. A case report may be the catalyst that sows the seed for an academic career.

In most case reports, authors simply describe unique findings or associations of one or more diseases, and the case report contributes little in terms of long-term significance to the academic community. However, this is not true for every case report. The publication of a single case report may lead other authors to recognize similar cases in their institution and subsequently to produce a scientific finding that advances our knowledge of a particular disease. In addition, a case report in which the authors describe a unique reaction to a drug or contrast agent may alert other radiologists to the possibility of a serious problem and may increase awareness in the medical community in general. Furthermore, a unique interventional technique described in a case report that is presented to the interventional community may be rapidly adopted into common practice. In other words, a case report may introduce a new idea or technique and stimulate others to perform larger trials.

Another reason to support the publication of case reports in a journal is that many readers find case reports an enjoyable part of a journal. Sometimes reading through lengthy double-blind multicentric trials with a plethora of statistics can be tiresome, and a case report affords a welcome break and makes the journal more digestible.

In summary, the era of the case report is in rapid decline. It makes good intellectual and economic sense that major journals stop accepting case reports, and this trend will likely continue. However, although we accept the demise of case reports, it is a useful exercise to recognize that case reports have had an impact in the academic theater. Their demise deserves a fitting epitaph, and it is important that we do not forget the significant contribution that they have made in the past and the fact that with their demise we may also lose some of the unique features case reports offer.

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