|Year : 2014 | Volume
| Issue : 2 | Page : 113-114
The benefit of a case report
Terence J Ryan
Department of Dermatology, University of Oxford and Oxford Brookes University, Wilts SN8 3OZ, United Kingdom
|Date of Web Publication||21-Apr-2014|
Terence J Ryan
Department of Dermatology, University of Oxford and Oxford Brookes University, Brook House, Brook Street, Great Bedwin, Wilts SN8 3OZ
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ryan TJ. The benefit of a case report. Indian Dermatol Online J 2014;5:113-4
The ornithologist gazes through binoculars and squeals with delight when identifying a bird not previously ticked off in his Book of Birds. The Botanist scanning the fields and mountain sides seeks new specimens identified by the leaf or bloom shape, color and the presence or absence of prickles. The stamp collector delights in the absence of perforations, an unusual watermark or a flaw in the design.
To people who do not belong to such groups of collectors they are all eccentrics indulging in a hobby which doesn't exactly contribute to improving the world. Is there a benefit? The Royal Academy of Arts of London, Magazine has recently described it as addictive or shopaholic, compulsive, a psychopathology, a crazy pursuit or at least a sign that you love your profession.
What then of the case report published by dermatologists? Why do they do it? What would a positron emission tomography scan of the brain record during the process of recognition of a physical sign? Would the hippocampus or cingulate nucleus light up in the excited collector thus demonstrating that the limbic system is at work and emotion plays a role in generating the excitement of recognition of a new or rare physical sign?
Dermatology is all about naming physical signs. However, it requires seeing, touching feeling, and even smelling. It is thus likely to involve a scattering of sites in the brain. The recording requires illustration and that means, today, having a camera at the ready. If the resulting illustration is out of focus or too dark the emotional center will not light up. I remember Bill Reed, an American Dermatologist who every one admired for his enthusiasm. He would squeal with delight when shown a new physical sign. What he liked best was for the physical sign to be a moving one and he went all over the world recording physical signs that moved using a cine camera.
Some dermatologists are better at recording case histories than others. A good story certainly helps and in the company of an enthusiast for a sport, we all know of the bore who tires one out by recitations equivalent to the hole-in-one of the golfer, and one no longer approves of stuffed tigers or collections of rare eggs diminishing important species.
What then is to be said in praise of the Dermatologist who publishes case reports? He or she clearly is expert, must be a skilled photographer and writer. He or she should be well read and that includes knowing the older literature. If the tale told can be a detective story or end with a surprise conclusion that helps to make an impression. The case reporter is a hunter gatherer probably with genes inherited from cave men who would draw the tale of a hunt on mammoth tusks or on cave walls and bore his family and tribe with tales of his successes. Today, the case reports often benefit by team work. The solitary hunter gatherer recruits help from other tribes identifying the location of the best examples and seeking additional skills from experts, the best at genetics are dependent on identity and clear authoritative descriptions so that the accuracy of their laboratory studies is ensured. The weirdest specimens become scientifically meaningful when the genetic defects are exposed. Commonly the cross border histopathology laboratory or the microbiologist may be recruited. Some of the best case reports are international and indeed weaknesses in case description may be to too little willingness to share.
There was a time when congresses supplied collections of case histories and some of these like the prewar Nekam's Atlas are unequalled reference books of the bizarre in black and white.
Today, we may see the hunter gatherer's records displayed up to 40,000 years after the event. What is sad about today's case report is that its educational role is short lived. Young Dermatologists for whom the case report is written as an educational tool glance only transiently at such reports and do not even read the whole story. While spot diagnosis is still an expected skill of the Dermatologist, backing it up with a good story and even requiring the owner of the spot to reveal its holistic background is giving way to the short term practice of taking a good photograph. Touching, smelling and history taking are forgotten skills not practiced by a camera.
The Poisons Library of Guys Hospital London issued photos of poisonous plants together with "feelies". This was a box of plastic smoothies or prickles. At first they were colored but this proved less instructive than being all just one color. Oddly black and white feelies proved easier to recognize. Coloring them led to confusion. The digital camera is less good at definition and color than the older Kodochrome slide and when in the first edition of the Oxford Textbook of Medicine I used Black and White photos from the early 1940 collection of the Oxford Department of Dermatology there were some reviewers who singled out for praise that you could feel what they displayed and empathize with story told by the legend.
May be, it is time to rethink the presentation of case reports in publications and not rely on the contemporary digital camera for doing the best job.
I am of an era when medical students were boxed round the ears if they did not distinguish a macule from a papule or nodule. Touching was essential. However, the Dermatologist who taught me did not believe in asking for a story, for that purpose she had a psychiatrist sitting in on the clinic in case talking to the patient was necessary.
The Editor of this Journal Shyam Verma is famed for his case reports. The reason for this is he has the camera at the ready, he describes in the best of English writing what he has learned by touch and his history taking ensures that every photograph has a legend that is well worth reading. It has been my habit to ask that legends are written in full early in the development of a case history to ensure that they impart the full educational value of the case report. Today with the readership no longer taking in every word it may be the legend that will be the only writing that is read.
Case reports add to a journal's readability. When well-illustrated with pithy legends they may ensure the journal's popularity. They are also often the first publication of a young dermatologist and once in print his or her loyalty to the journal may be life-long.