“That’s a great case. Why don’t we write it up?” It’s a question I’ve heard many times throughout medical school, residency and fellowship. It’s typically intended to be more of a politely worded request than a rhetorical question. We must acknowledge that the process of writing, editing and submitting a case report is onerous, but it can provide immense utility to other physicians, especially with respect to unique diagnostic and management dilemmas that are not covered elsewhere in literature. Indeed, your words can travel far and wide, finding themselves not only in peer-reviewed journals, but also potentially in trade and association publications with even broader appeal, like The Rheumatologist.
Assuming you work up the courage to write a case report, how do you begin? As a person who enjoys reading case reports and has written a few himself, I have six tips to guide you along the way:
1. Assemble a capable team. Case reports can be written by an individual, but most likely, you will end up working with collaborators to help share the burden of the workload. Enthusiastic medical students are commonly roped in, who are then tasked to write parts of the manuscript or perform literature searches. Of course, medical students should be rewarded for their hard work, and if their efforts are significant enough, should be entitled to be first author. You should also be aware that there are significant disadvantages of outsourcing work to medical students. For one, medical writing is a skill that medical students and residents are often not well versed in. As a fellow, it becomes your obligation to teach them the ropes, and so patience in writing and rewriting is absolutely imperative.
Additionally, due to the multidisciplinary nature of rheumatology, other specialists also tend to tag along. I have personally found the insights of pathologists and radiologists to be invaluable when writing the discussion section of a case report. But that’s only when they actively participate. Adding yet another name to the case report because “they were on the case” or because they provided access to a pathology slide or radiograph only dilutes the contributions of other authors.
More important is identifying a mentor who can look critically at your work and revise it accordingly. Usually, this is the attending physician on the case, but others can function in that role. And while it seems best to get someone who has a knack for editing, if your mentor is too fastidious, it can lead to delays, frustration about the direction of the report and even clashes that make writing a miserable chore.
Regardless of who joins you, it is vital to identify the roles of all of the contributors early in the process. Because the roles of first, senior and corresponding authorships are so important, these need to be discussed and negotiated along with the associated expectations.
2. Set realistic deadlines. Although case reports are not as time consuming as other types of scholarly work, case reports can still take up quite a bit of time. And time is something that we fellows do not have. Therefore, it’s important to set deadlines and place them on your calendar. Of course, these have to be flexible, especially if you are dealing with collaborators whose schedules you have little control over, but if the case report is not at the forefront, it’s likely to be forgotten altogether.
3. Figure out your angle. Case reports are, in essence, short stories. And just like short stories, they have themes, characters, settings and plots. In fact, the strength of a case report lies in the interplay between these various facets of storytelling.
Whether you want to set it as a detective story, in which a culprit disease is slowly identified through methodical reasoning, or a futuristic fantastic illustration of a new medication to treat disease, the choice is essentially up to you. One common misconception is that rarity imbues a case report with value and that simply relaying the details of an uncommon disease will lead to compelling reading. In fact, it’s quite the opposite—without making the argument that this narrative has importance to other patients, it might come across as a fish story that readers are likely to ignore altogether.
4. Know who you are pitching to. It’s also incredibly important that, very early in the process, you consider which types of journals or medical news magazines you would like to submit your case report to. Certain publications have very particular formats that authors should be aware of so they can tailor their work accordingly. Some only offer to publish letters to the editor or clinical communications, which are quite short. Others, like Arthritis Care & Research and the New England Journal of Medicine, have extended Clinicopathologic Conferences (CPCs), in which there is running dialogue interspersed with the case presentation and can run for several thousand words. Knowing the publication’s audience is just as important. The discussion section of a case report intended for a rheumatology journal should be approached very differently than one intended for a general internal medicine journal.
5. Understand what’s relevant to include. Although case reports are essentially short stories, it is important to remember that a case report is also an important piece of scientific work. Somebody may pick up your case report and use the information that you presented in order to alter their clinical management. Therefore, there is no room for fanciful embellishments or errors of omission. At the same time, good case reports must be concise enough to avoid incorporating extraneous information. Thus, the challenge of writing a case report is that you have to distill a complex series of events into a compelling narrative without distorting the facts of the case.
6. Write your introduction and conclusion first. If you read enough case reports, you will recognize that almost all case reports have the same formula for the introduction. It starts with a general explanation of the disease or condition in question, and then quickly narrows down to the knowledge deficit that the case report hopes to address. Following this is the statement of scope: “We further review the pathophysiology, etiology, differential diagnosis, … of this disease.” Conclusions are similarly formulaic, but instead of presenting the problems, the writer simply has to echo the introduction, while reiterating the salient points mentioned in the discussion. Therefore, writing the introduction and conclusion first enables you to acquire low-hanging fruit and start tackling the clinical presentation and discussion sections, which are considerably more variable and difficult to craft.
So should you write a case report? Certainly, if you have time and can expend the effort. It’s a great way to boost your curriculum vitae, improve your program’s reputation and disseminate knowledge. Perhaps the biggest motivator is the sense of pride and accomplishment you obtain when you see all the long hours and hard work poured into this labor of love finally make its way into print.
Bharat Kumar, MD, is a second-year fellow at the University of Iowa pursuing a dual certification pathway in rheumatology and allergy/immunology. Dr. Kumar has a special interest in medical education, journalism and ethics. Follow him on Twitter @BharatKumarMD and check out his website.