My first published papers were case reports of interesting psychiatric patients I treated as a resident: a woman with thyroid-induced psychosis miraculously “cured” by a subtotal thyroidectomy, the first-ever report of myoglobinuric renal failure due to tardive dyskinesia, identical twins who shared the same delusions (folie à deux), and several patients suspected of having Munchausen syndrome.
However, I was advised by my chairman to never draw conclusions from a study with an “n of one,” because there is considerable doubt about the value of information pertaining to only one patient. “Are the data reliable and replicable?” he asked. “Is the conclusion generalizable to other patients and populations?”
True to form, in 1984, the American Journal of Psychiatry decided not to publish case reports apart from brief letters to the editor deemed to have unique educational value. Other journals followed suit.
Around the turn of the century, there was backlash against the suppression of case reports. The demand for their publication increased, leading to cases reported as “clinical conferences,” “perspectives,” and “hindsight.” The development of online publishing cemented the resumption of single-case reporting, with the British Medical Journal paving the way.
The time was also ripe for narrative medicine writing — “to acknowledge, absorb, interpret, and act on the stories and plights of others," according to Dr. Rita Charon. Psychiatry witnessed a resurgence in single-subject research in psychotherapy process and outcomes. The individual case report became a powerful tool to illustrate complex clinical decision making relevant to the practice of holistic and evidence-based medicine.
However, the rules of evidence-based medicine relegated case reports to the lowest level in the hierarchy of studies. Evidence gathered from randomized clinical trials and meta-analyses was given much more weight than information gleaned from case studies. I stood by the case report as an important source of knowledge for clinicians in their quest to better understand their patients’ diagnoses and treatment options.
The learning that occurs by reading a case report is derived not only from the presentation of the case – often a forme fruste – but also from the case discussion. The discussion is typically enriched by an extensive search of the medical literature. The bibliography further invites clinicians to read the references to gain a deeper understanding of the clinical issues.
My flirtation with case reports was purely accidental. In my last year of medical school, while doing an elective rotation in psychiatry, I encountered a patient who seemed to have a severe infection. She was stiff, sweating, febrile, and not fully oriented. Why was she admitted to the psych unit? I thought. The referring physician included a brief note saying the patient had recently received quite a bit of antipsychotic medication for an unknown type of psychosis.
The admission note wasn’t much to go on, which in itself piqued my interest. Additionally, I was beginning to develop an awareness of harmful side effects of psychiatric medications. So, I visited the medical school librarian (circa 1980, pre-Google), who kindly conducted a computerized literature search using the patient’s symptoms as search terms.
The search yielded only one relevant article — a summary of the world literature, consisting of about 60 cases, of a condition called “neuroleptic malignant syndrome” (NMS). The hallmark symptoms of NMS were nearly identical to those of my patient: rigidity, hyperthermia, autonomic dysfunction, and altered mental status.
Moreover, the author of the article was a psychiatrist practicing at the Veterans Affairs (VA) hospital in my hometown of Philadelphia. What a fortunate coincidence! I called him and explained the nature of the case. He recommended that I withhold all psychotropic medication and treat the patient supportively. Following his advice, the patient recovered in about a week.
I wrote a paper describing the diagnosis and treatment of NMS, and it won second place in a residents’ writing competition sponsored by the Philadelphia County Medical Society. The case was eventually published in “Psychiatric Annals,” along with another case of NMS I encountered during my residency.
I arranged a meeting with the VA psychiatrist and proposed the idea for a book about NMS and related conditions, such as heatstroke, malignant hyperthermia, serotonin syndrome, and others. The book was well received, and a second edition was published 14 years later as new information and research became available.
Today, the symptoms of NMS are stated as a precaution in virtually all journal advertisements and television commercials marketing medication for depression, bipolar disorder, and schizophrenia. It is gratifying to know that alerting patients to this very serious condition was sparked by a single case report culminating in a textbook.
Contrary to medical advice, I sometimes urge medical students and residents to “look for zebras,” or at least research and write about patients with mysterious illnesses or conditions that stymie them. Learning how to write case reports should not become a lost art. Including case reports as publications in one’s CV will command attention in competitive residency and job markets.
To be publication worthy, case reports should contain the patient’s informed consent and fulfill one or more of the following criteria:
- Establish a clear purpose and elucidate teaching points or “takeaways.”
- Describe a “first” or something new and unique — for example, a disease or observation.
- Report unusual therapeutic drug effects.
- Alert clinicians to serious, potentially fatal, adverse reactions and complications.
- Provide a useful clinical pearl, acronym, or mnemonic.
I wouldn’t have been as attuned to patient nuances had I not first dabbled in single case methodology and had the discipline to write about my patients. Publishing a case report, especially early in a physician’s career, is a scholarly activity that positions a doctor to become a “triple threat” — an educator, clinician, and researcher.
Share your experiences with clinical case reports in the comment section.
Arthur Lazarus, MD, MBA, is a member of the Physician Leadership Journal editorial board, a two-time Doximity Fellow, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia.
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