For most junior doctors their first experience of publication will be writing a case report. BMJ Case Reports Editor-in-Chief, Seema Biswas, offers some advice on perfecting your write-up.
Writing up a memorable case with your team is a valuable learning experience. It is the opportunity to research more about a case, search the medical literature, look up and compare clinical guidelines, ask probing questions about the pros and cons of management decisions and, most of all, assert your point of view in the medical literature.
As evidence based medicine standards go case reports are level 5 evidence (below clinical trials and case series) but case reports do have their place. We learn from our discussion of cases we manage every day. It helps to discuss unusual presentations, complex symptoms, ethical or practical challenges, near misses, pitfalls and how complications may present and are dealt with. The debate is an educational one and case reports are an ideal educational resource for real case based discussion.
A common perception is that only rare or novel cases are worthy of publication. In fact, we learn far more from common cases that present in an unusual way or common management pathways that meet an impasse or result in an unexpected outcome.
My advice for writing up a case are to find one with valuable educational lessons for junior doctors or medical students. The patient may be someone you meet as a student or junior doctor, or a patient you looked after on a medical student elective. Take any clinical pictures you need to illustrate your points and then write-up the case using the following structure:
Summary: Try to project the lessons of value and points of interest so that these are immediately apparent to someone reading your report. You may choose to type this section last as your report takes shape but this will be what captures the attention of your audience.
Background: This is essential information that sets the scene and explains why certain symptoms or complications may have arisen during the course of illness.
Case presentation: For most of us this is frequently the easiest section to begin writing. This is an outline of everything that happened to the patient from the time of presentation to discharge. This is ideal for you to type as you are most likely to have completed most of the case note entries yourself and merely need to consult your notes. Be sure to include all relevant results and write these in full using internationally recognised units explaining any abbreviations, e.g. “The patient was hypotensive with a blood pressure of 130/80 mmHg and had developed neutropenic sepsis with a WCC, white blood cell count, of 2.1 x 109/l”
Investigations: This is where radiological images illustrate your results and good pictures are extremely effective.
Differential diagnosis: Rather than listing these, what is crucial is to demonstrate is how differential diagnoses were formed and diagnoses excluded as the patient was worked up. Clinical reasoning is fascinating as an entity in itself, but case reports are a brilliant opportunity to demonstrate how diagnoses are teased out through clinical problem-solving. This is where case reports really come into their own and earn their place amongst the medical literature.
Treatment: As an editor, the best case reports present the case, investigations, diagnosis and treatment as an honest and reasoned process where management decisions are explained clearly. Clinical judgments and treatment plans, therefore, make immediate sense, especially to a doctor of a different specialty.
Outcome and follow up: These give the clearest idea of the progress of a case. All too often this is neglected as inpatient teams may be disconnected from outpatient care. This information is crucial, however, and tracking a patient’s progress after discharge is, of course, excellent practice for the inpatient team.
Discussion: There is no need for the discussion to be a summary of all the literature about a particular clinical problem. Focus on points that make the case notable and where lessons can be learned; this may be a mechanism of injury, a pitfall in the interpretation of investigations, the suitability of appropriate clinical guidelines, necessary departures from these guidelines or their adaptation in a particular scenario, the management of challenging complications … there are innumerable possibilities!
Learning points and take home messages: These are essentially your final conclusions and serve to crystallize your thoughts on exactly why you think this case is of value and what we can learn. You may find this very effective in focusing your thoughts when you begin typing the case report.
The patient’s perspective: This may be a most enriching contribution. I would urge you to involve patients in the process from the beginning as this is likely to result in a well-rounded account and the process of obtaining consent for images and publication is rendered more meaningful.
As an editor, it is often writing style or grammar that fail to do justice to a case report. A well-written case with clear learning points is likely to be published. In modern medical portfolios where publication is essential for job applications and continued professional development writing up notable cases is both an educational and career ‘no brainer’.