YOU CLOSE THE FILE ON YOUR MOST RECENT PATIENT who has successfully completed her course of treatment and think to yourself, “This would be a good case to write up for a journal.”
“Case studies are important to help identify issues that merit additional, more in-depth investigation,” notes Ronald Farabaugh, DC, a member of the Council for Chiropractic Guidelines and Practice Parameters (CCGPP) and founder of the Chiropractic Healthcare Information and Research Office, Ltd. “Clinicians are particularly well-suited to draft and submit case studies given the volume of clinical patients they see and their positive experiences related to a variety of conditions.”
But before you can even get started writing up your promising case report, you think of all the reasons not to: It takes too much time; you’ve never submitted a case report and wouldn’t know where to start; it probably wouldn’t get accepted anyway.
Submitting a case report can be easier than you think, Dr. Farabaugh says. “Drafting a case study is significantly easier than conducting extensive and expensive research like randomized controlled trials. Most clinicians already possess the skill set required to submit a simple case study, but many avoid the process due to fear of the unknown.”
Indeed, the process has already been set out for novice case report writers, step by step, by a group of journal editors and other leading stakeholders known as the CARE (CAse REports) Group. Case reports, as explained on CARE’s website (www.carestatement.org
), “are professional narratives that outline the diagnosis, treatment and outcomes of the medical problems of patients. Information from case reports provide feedback on clinical practice guidelines and offer a framework for early signals of effectiveness adverse events and cost.”
These tools, the CARE Checklist and the Case Report Writing Templates, have become widely accepted by leading scientific journals, says Cheryl Hawk, DC, PhD, CHES, executive director of the Northwest Center for Lifestyle and Functional Medicine at the University of Western States. In her case report writing seminars, Dr. Hawk goes through the CARE guidelines step by step. “If people will follow these guidelines, then they have a much better chance of having their case reports accepted, especially in the journals that are now requiring this format. It’s pretty prescriptive and tells you exactly what they want.”
And the guidelines are surprisingly simple, just a two-page document. After ensuring patient consent, de-identifying all patient data, disclosing any conflicts of interest and obtaining any necessary approval from an ethics committee or institutional review board, here’s what is called for:
The title should include the words “case report” and a description of what you find of greatest interest about the case.
Provide a 200-word summary of what’s most important about the case, such as presenting concerns, diagnoses, interventions, outcomes and main lessons to be learned from the report.
Two to five key words that will help potential readers find the case report.
A brief summary of background and context.
Describe the patient, including relevant demographics, current presenting concerns and related past history and interventions.
These include the patient’s medical, family and psychosocial history (including lifestyle and genetic information, pertinent comorbidities and interventions; along with your physical examination focused on the important findings). This section also includes any test results.
A table, figure or other type of graphic with specific dates involved in the case. One example can be found at www.care-statement.org/case-report-examples
DIAGNOSTIC FOCUS AND ASSESSMENT:
This section should describe all diagnostic methods used (e.g., laboratory testing and imaging results), any diagnostic challenges faced (e.g., difficulty completing certain evaluations, language barriers), your diagnosis and reasoning, including other diagnoses you’ve considered and any prognostic characteristics.
THERAPEUTIC FOCUS AND ASSESSMENT:
Describe all interventions you have prescribed, along with the dosage, strength, duration and frequency of treatment.
FOLLOW-UP AND OUTCOMES:
Here is where you describe the full clinical course of the case, including follow-up visits, patient adherence, changes to your treatment plan and unanticipated or adverse events.
This section allows you to discuss the case at greater length, and make the case for its significance and utility. Explain your main findings, explore the reasoning behind any conclusions you draw and discuss how the case might be applicable to a broader population. The guidelines also call for an exploration of the strengths and limitations of the case report along with references to any relevant scientific literature. Conclude with any useful take-home messages for the reader.
What to Avoid
Even with clear, well-established guidelines for writing case reports, many authors can make rookie mistakes, says Dr. Hawk. Have you ever made any of these?
1 Not following the journal’s author instructions. The CARE guidelines come in a very useful general template, but each journal will have its own unique preferences and quirks, down to things like type font and print spacing in some cases. “Every journal has instructions to authors: print them out and do exactly what they tell you,” says Dr. Hawk. (For example, does this journal even accept case reports?) “If you don’t submit in a professional manner, then you’ll start out with several strikes against you already.”
2 Using chiropractic jargon. “Don’t assume that the world knows about chiropractic. Most of the world doesn’t even know that there’s more than one chiropractic technique,” Dr. Hawk says. “So if you use a chiropractic term, always define it — even something as commonly used as ‘subluxation.’ And don’t put the name of your technique in your title. The journal editors almost certainly won’t know what you’re talking about. So just assume that the reader is not familiar with your technique and explain how it’s done.”
3 Overstating your claims or making unsupportable assumptions. This happens quite often, laments Dr. Hawk. “I’ve seen authors go on for three pages on physiology and how their technique affects certain neurological tracts. You don’t know that unless you’ve also done brain surgery on the patient.” If you have a hypothetical explanation for how you were able to achieve a positive outcome in your case, back it up with references from the literature. “Don’t make statements like, ‘This case proves that chiropractic is helpful in these situations,’” Dr. Hawk says. “A case report can’t prove anything. You can say, ‘In this particular case, the patient appeared to experience clinical benefit from the treatment,’ and suggest that further controlled research is warranted. But without a control group, you can’t claim cause and effect.”
4 Using non-peer reviewed literature or textbooks as a reference. “There’s not usually a good reason to do that,” says Dr. Hawk. “If you’re doing a comprehensive literature review and want to cite all the articles that refer to a particular question, that’s fine, but normally Dynamic Chiropractic is not something you’d cite in a peer-reviewed journal. The same goes for textbooks, unless there’s a specific quotation you see as essential to cite.”
5 Using outdated references. “I’ve seen some people who really think that 1986 is the same as 2015!” marvels Dr. Hawk. “You always have to look at the dates on your citations. Maybe there’s a specific reason why an older reference needs to be included, but normally, you should make sure your references are all no more than five years old.”
6 Not running spell-check and grammar check. Yes, people really neglect to do this! And because spell-check isn’t perfect, ask a trusted person to read through the manuscript for you — a spouse; a friend; a professor at your college. They’re not necessarily assessing the scientific merits of the case report, but they can tell you if it makes sense, and they can spot grammatical, spelling and usage errors that you may miss because you’ve gone over the paper so many times.
7 Not recommending a reviewer. Most journals will ask you to recommend a reviewer or reviewers for your article. Even if they don’t, it’s a good idea to suggest reviewers in your cover letter. “Sometimes that can make the difference between having your article reviewed and having it sent back to you unread,” says Dr. Hawk. “The editor may not want to comb through the files to find someone. I had an article rejected years ago because the journal claimed they couldn’t find anybody to review chiropractic! Don’t give them an out.” And when you suggest a reviewer, don’t just try to pick the biggest, most impressive name you can find. “Pick someone you know and whom you know will be friendly. That’s perfectly fair,” says Dr. Hawk. “It will be blind reviewed, but if you suggest someone you know, who understands your technique or point of view, it will be a much more friendly review. Don’t pick a big expert just for the name, only to have them rip you limb from limb.”
8 Learn from the reviewer reports. Don’t give up if you get a critical review! “When I had just started doing research, I felt totally crushed by the criticism,” says Dr. Hawk. “A lot of times, people just stop right there. As an editor, I try to be encouraging so that authors don’t just disappear with their tails between their legs, but not all editors do that. Remember: Unless the review categorically states that it rejects your case report, you have the chance to resubmit it. Go through the reviewer comments, take them one at a time, number them, and say what you’ve done to fix each issue raised.” And take the comments graciously — thank the reviewers for the helpful suggestions, and don’t argue with them or suggest that they just don’t understand. “Usually, if the reviewer is confused, the author didn’t make something clear enough,” Dr. Hawk says.
Getting your article published in a peer-reviewed journal is reward enough for writing a good case report — but there can be additional benefits. Dr. Farabaugh notes that once you’ve prepared a strong in-office case study, you can submit it to local medical professionals in order to help them understand the clinical practice of a typical chiropractic physician. (Again, with appropriate patient-informed consent.)
“Most medical professionals have never been in a chiropractic office, have skewed perspective of what we do and have no idea of the real results we obtain,” he says. “A narrated PowerPoint, in case study format, is a creative and efficient way to educate those outside of chiropractic. Development of a PowerPoint is really easy and basically just mirrors how you process a patient in your office.”
He recommends adapting the case report using the following slide presentation template:
• Introductory slide: your picture, clinic name and contact information.
• Biography slide: Five to 10 bullets/points of interest about you and your accomplishments.
• Brief history of patient.
• Brief exam findings.
• Radiology images.
• Radiology findings (MRI, X-ray).
• Complicating factors such as obesity, age or deconditioning.
• Treatment plan.
• Pictures of treatment. “Most physicians think they know chiropractic, but they really don’t,” says Dr. Farabaugh. “Show them what you did and the equipment you used.”
• Guidelines. Explain the nationally accepted, evidence-based guidelines for course of treatment and evaluation.
• Results of care: Pain levels at original visit and at final visit.
• Results of care: Functional improvements at original visit and at final visit.
• Lessons learned.
• Summary: Describe what happens when the medical professional makes a referral to your office.
• Contact Information.
“You can easily turn an excellent case report into a slide presentation for your local physician community,” says Dr. Farabaugh. “Both a case report published in a peer-reviewed journal, and a strong, well-supported cast report slide, can be of great benefit to your practice.”
Don’t Forget HIPAA!
Patient privacy is very important when writing a case report. For the latest on HIPAA requirements, read Navigating HIPAA in the Electronic Age, March 2015 ACA News, Page 22 at www.acatoday.org/content_css.cfm?CID=5630
. Also, visit www.acatoday.org/HIPAA
Gina Shaw is a contributing writer.