Editorial: The Increasing Relevance of Case Reports in Medical Education and Clinical Practice – and How to Write Them

PubMed is a publicly available search facility for more than 36 million citations in the biomedical literature, mainly from MEDLINE, the National Library of Medicine (NLM) journal citation database [1,2]. Figure 1 shows the ten-year trend in submissions to and publications in the American Journal of Case Reports between 2012 and 2022. A search of PubMed between 2012 and 2022 shows that the American Journal of Case Reports (Am J Case Rep) published more than 3,500 case reports and case series, including 476 publications in 2022 alone (Figure 1) [1,3]. For the first time, in 2022–23, the American Journal of Case Reports achieved an impact factor (IF) of 1.2 [3]. These data highlight some important facts about the current status of publications of case reports in the medical literature, which are that the number of publications continues to increase and that the clinical importance of case reports and the journals that publish them may have been undervalued [4].

The presentation of the case of a patient, including the history, diagnosis, management, and any novel aspects, is a fundamental part of medical education before and after medical qualification, which continues throughout the clinical career [4,5]. However, opinions still vary on the relevance of publishing case reports and case series to medical education and practice [4,5]. There is the view that they are of limited value at a time when medical research, drug development, and the results of clinical trials dominate the medical literature [4,5]. However, evidence also supports that they are undervalued and remain relevant [6]. In the last 15 years, the number of journals that publish case reports has increased rapidly, in line with the increase in open-access publications [5]. Currently, more than 200 journals indexed in MEDLINE and identified on PubMed publish case reports and case series [2]. At this time, the NLM Medical Subject Headings (MeSH) thesaurus search terms, ‘case report’ and ‘case series,’ identify a total of 2,417,365 case reports and 170,445 case series published in journals indexed in MEDLINE and identified on PubMed [2,7]. In 2022 alone, there were 77,800 published case reports and more than 15,000 published case series [2].

The history of medicine has shown some important landmark case reports identifying medical conditions, which may have undergone delayed recognition without these publications. Also, single case reports and case series have driven future observational and experimental clinical studies. For example, as early as 1869, Beard published the first description of ‘neurasthenia’ in the Boston Medical and Surgical Journal [8]. The condition of neurasthenia was later identified as myalgic encephalomyelitis (ME) or chronic fatigue syndrome (CFS). In February 1915, during World War I, Captain Charles Myers, a British military doctor, first identified and described the syndrome of shell shock in a publication in the Lancet [9]. Before this publication, soldiers with shell shock were assumed to be either malingerers or cowards. In 1949, a chance observation reported the association between lithium and the control of mania in patients with manic-depressive disorder [10]. The side effect of congenital abnormalities in infants born to mothers who took the anti-emetic drug thalidomide in the 1950s and 1960s was first reported in 1961 as a Letter to the Editor in the Lancet [11].

This publication was followed by case reports and case series, highlighting their role in pharmacovigilance [12]. More recently, in 2008, a case series published in the New England Journal of Medicine identified the beneficial effects of systemic propranolol on the treatment of infantile hemangioma [13]. Therefore, case reports and case series can be expected to continue with their essential contributions to the medical literature, medical education, clinical practice, and patient safety [14].

Since 2020, the COVID-19 pandemic has significantly impacted the number of manuscript submissions and publications [15].

Initial reports were of the symptoms, presentation, and outcomes of SARS-CoV-2 infections, which then described the long-term effects of COVID-19 and responses to new treatments and vaccines [15]. Concerns have been expressed that this sudden rush to submit case reports on COVID-19 resulted in a rapid increase in manuscript submissions that was not matched by the number of publications due to reduced manuscript quality [15]. Between January 2020 and September 2023, PubMed identified approximately 20,000 published case reports and more than 5,000 case series involving COVID-19 [2]. The recent effects of the COVID-19 pandemic on manuscript submissions and publications by the American Journal of Case Reports are also shown in Figure 1. The data in Figure 1 support the rapid increase in publications of case reports by this journal during the COVID-19 pandemic but also show a much greater ‘spike’ in journal submissions. Between 2020 and 2022, the peer review process identified case reports that fulfilled current publishing guidelines and the criteria for reporting clinical cases (Tables 1 and 2).

Table 1 summarizes the things to do and what not to do when preparing a manuscript as a case report, including the ethical requirements and preparation of the supporting clinical material. Table 2 summarizes the essential things to do and include and what not to do or include when writing the case report. Case reports should be reported ethically and credibly, with attention to the manuscript content, patient informed consent for publication and respect for patient confidentiality and anonymity. (Tables 1 and 2). All journals that publish case reports and case series, including the American Journal of Case Reports, publish guidelines or instructions for authors on preparing the manuscript, which should be followed [16]. Also, the CAse REport (CARE) Statement and Checklist provide clear recommendations for what to include in case reports [17,18]. The International Committee of Medical Journal Editors (ICMJE) (www.icmje.org) provides standardized guidelines for the ethical requirements, preparation, and formatting of all manuscripts submitted for publication, including case reports [19].

Case reports are often the first publications for medical and surgical trainees at the start of their careers [20]. Some medical schools provide training in writing formal case reports as part of the clinical curriculum, often as part of the clinical pathology or laboratory medicine program, supported with guidance from clinical tutors [20,21]. In January 2023, Gupta and colleagues highlighted the importance of writing and publishing case reports by medical trainees and clarified the requirements for time, training, and mentorship [22]. These authors and medical educators designed and used a synchronous, virtual workshop that included trainees and academic faculty from several medical schools [22]. Trainees and clinical mentors discussed the contributions of case reports to the medical literature, identified the key content required, and the features of interesting and informative case reports [22]. Two months after the workshop, medical trainees gained confidence in identifying clinical cases with rare presentations and rare cases of interest, working with clinical mentors, and writing case reports with mentorship [22].

The major merits of published case reporting include identifying rare diseases and syndromes and complications or side effects of treatment, pharmacovigilance, and clinical education [4]. The limitations or cautions of the case report include the inability to generalize, the lack of establishment of a cause-effect relationship, the dangers of over-interpretation, and the pursuit of the rare or unusual case (the ‘first case’) rather than the informative or educational case [4]. Attempts have been made to revise the case report genre and to integrate the medical report with a narrative approach [23]. However, the narrative case report, or patient’s story, has met with limited success, possibly because of the difficulty in identifying content relevant to the clinical case, ethical concerns, and concerns with patient anonymity [23].

Conclusions

The future of the case report and case series remains assured as new diseases, syndromes, and treatments and their applications and side effects constantly evolve and require early and clear reporting in the medical literature.