A thorough and detailed analysis of a single patient history, clinical presentation, course, and outcomes often helps in improving our understanding of the pathophysiological mechanisms of disease. However, at times, there are certain nuances in every patient that cannot be explained by large dataset-based manuscripts, where there is every chance that several minor, but relevant aspects can be ignored. Therefore, single patient case reports or a short series of patients provided valuable information that can be very useful clinical snippet and has the potential to lead into newer research ideas. I am sharing below some of my thoughts on how one should focus on writing a case report (disclaimer: I am not an expert!).
Before I list my “pearls”, I would like to state that the scientific depth and accuracy of your thought process at the time of the clinical visit with the patient will ultimately guide your chances to the publication.
1. Identify phenotype and presentation
It is vital for the treating clinician to understand the clinical presentation and be able to categorize the patient into a particular phenotype. If you are unsure, there are chances that you may be missing a diagnosis (since the disease may be rare), and in such situations, it is better to consult your peers. This approach has two great advantages: peers can help you decide if the case is indeed unique, and provide you additional clues that can help you investigate the patient or obtain ancillary investigations.
2. Interpret the tests
An important part of writing the report is to be able to correctly interpret all the data such as imaging features, results of laboratory assays, and advanced tests such as polymerase chain reactions and biopsies. If there are fallacies in the interpretation, these will be most likely picked up by the reviewers, and will ultimately impact the acceptance of your findings. There are innumerable advantages of holding multi-specialty meetings and open discussions so that you are reasonably certain of the interpretation, and alternative explanations, if any. We often come across reports which state, “the authors did not feel the need for x test because…”. If these statements are not backed by a thorough review of the literature, it might not be acceptable.
3. Do not limit because of affordability
We all work with limited resources. But when it comes to publishing a case, there are many things at stake. The scientific community cannot publish a half-baked cake since it can have serious implications when another clinician applies the same knowledge to a particular patient in their setting. As far as possible, try to do a complete examination, and avail all possible help in obtaining tests free/limited cost by collaborating with institutions.
4. Judge the uniqueness
Not all cases deserve publication. There are certain textbook-picture presentations, which need not be published since they do not add to the literature. There may be unique cases, but have been previously reported. If you have another such case, most likely it will not add to the literature. If you believe that your case is indeed unique (belief backed with significant literature search, and not a cursory google one), then make an honest effort in highlighting the rarity and the importance of identifying that feature. On the other hand, some very rare presentations also do not deserve publication. For instance, an adverse drug reaction (which can be patient-specific) cannot be attributed to a drug just based on a single report, and most journals discourage such submissions.
5. Documentation, documentation, and documentation
The heart of the case report is thorough documentation, including images and clinical notes. Since most case reports are written in retrospect, many authors are limited with their quality of images and completeness of clinical notes. The only way out is to pay special attention to those handfuls of patients that are challenging, and spending time with them during clinical visits. Once the disease has run its course, it is very difficult to go back and obtain fresh images/ancillary tests.
6. Detailed patient timelines (go back in history!)
A successful submission of a case report would consist of a detailed patient timeline. This can be done using carefully designed graphs and charts which plot various landmark events in the patients history including episodes of fever, newer therapeutic interventions, and resolution of symptoms. This provides the reviewer and the reader valuable insights that would lead to the appreciation of the manuscript.
7. Be concise, crisp and sharp
A case report typically has a word limit by most journals. The editors of journals aim to have a succinct case report published in their journals that provide the necessary information without “extra” or “low yield” text. Thus, each case needs to be revised and re-revised, especially by a senior author (in case the task of writing it up has been designated to a junior resident). I believe that a case report should be taken very seriously, and each submission must be carefully reviewed by the corresponding author (clinician in-charge) for accuracy and lucidity. Designating the task to an inexperienced young resident/fellow without supervision can often lead to rejections.
8. Good science survives!
If your case report has a good scientific value, even an average report will find favorable reviewer/editor responses. However, a decorated case with beautiful images but limited scientific content will be tough to pass by without a rejection (these can be submitted as a photoessay). If you have a case that provides new information that can be summarized in less than 300 words, it is best to submit as a case snippet, photoessay or an ophthalmic image. Journals would like to keep the space reserved for case reports for unique cases that cannot be described with such a tight limit. Make sure you put in the information wisely!
9. Choose the journal wisely
If you have a brilliant case report and submit to the wrong journal, you will end up wasting time (someone else may publish in the interim!) and obtain feedback that is of limited use. Having a sound knowledge of the aims and scope of the journal in advance can help you in various aspects such as: formatting the manuscript (I always keep it simple with Arial font size 12 with no extra formatting), designing the abstract, making the figures, limiting the authors, and finally, gaining acceptance. A majority of the systemic journals may not be interested in ophthalmic case reports, unless a detailed systemic workup (ideally with a team of doctors from other specialties) have been described. Nowadays, most journals do not accept case reports due to the lack of novel information in submitted manuscripts. However, certain journals do allow you to write to the editor who can convey their decision without a formal review (and indicate whether they are interested or not).
It is challenging to publish a case report. One must be prepared to receive multiple rejections and sometimes, seemingly “inappropriate” comments from the reviewers. However, it is important to understand that single patient case reports carry less scientific credibility (I am not saying it – it’s the Oxford Level of Evidence!). Therefore, such comments are common and should not discourage the authors. The key is persistence – if the authors can improve their manuscript and submit elsewhere, I encourage them to do so. If the authors feel that the manuscript suffers from several flaws and will face the same challenges during the second/subsequent submissions, it is best to stop persisting and hunt for another case.
Most colleagues believe that a case report is a good starter for a resident and fellow into the world of publishing. But a caveat in this approach is that each submission must be taken seriously by the corresponding author, and they must ensure that no report which is of suboptimal quality should leave his/her desk. Many senior ophthalmologists too, publish case reports occasionally, and it is always a good idea to read them thoroughly so that one learns the art of patient description and reporting. One last piece of advice: become a reviewer for a journal that accepts case reports; believe me you will be richly rewarded!