In Defense of the Case Report: Thoughts of an Academic Generalist

According to the Merriam-Webster dictionary, an expert is defined as someone who has or displays a special skill or knowledge derived from training or experience¹ and a medical specialist is defined as a practitioner or authority who devotes his attention to the study of a particular disease or a class of diseases.² 

Multiple factors seem responsible for the increasing level of medical specialization, including the public demand for special knowledge and skill, the geometric growth of data generation surpassing the ability of any single person to learn it; the emergence of new technologies requiring specific training; the generally unrestricted access of our patient population to the specialist; and the significantly higher payment to specialists in comparison to that of generalist, among others.^2-5

Primary care’s role includes managing and triaging undifferentiated symptoms, matching patient needs to healthcare resources, and assuring financial and geographical access to basic health interventions for the majority of the population.⁶ 

Academic generalists are expected to care for patients while simultaneously training the new generation of physicians. These full-time duties allow trainers to use the available educational resources to feed information to their trainees. But what would the trainers do if a new question has no evident answer? What if the review of the accessible literature was not enough? 

The Challenges

To solve this dilemma, let’s first consider the many issues that put academic generalists in a relatively disadvantaged position. First, the number of generalists has decreased drastically in recent years.^7,8 Therefore, this already strained workforce would struggle to fulfill a research role. Second, there is no specific funding opportunity available to support generalists who prefer to keep their focus of research all encompassing, rather than centered on specific topics. 

This, in turn, creates several problems. The largest funding institutions consider the researcher’s expertise when allocating their grants. Therefore, a clinician with questions pertaining to too many disciplines pays the price of his curiosity by decreasing the chance of being awarded with funds. 

Furthermore, most of the scattered resources are placed on funding randomized trials, set at the top of the evidence pyramid.⁹ Prospective research is then a virtually impossible task. To complete this vicious cycle, younger investigators will more likely prefer to join senior physicians with narrow expertise, increasing their own chances of being funded.

What’s the Alternative?

Retrospective research (eg, case-controlled studies or retrospective cohorts) is an alternative. However, beside the technical limitations of these investigational procedures,^10,11 they also demand funding and time—a scarce commodity in the academic setting, where patient care is at the center of the attention.

Case reports and case series suit the generalist academicians’ need to promote the advancement of science. Being that “all patients are interesting, but not all doctors are interested,”¹² case reports provide the interested physicians with the opportunity to straightforwardly take the case, or at least some aspect of it, to a higher level of understanding. This tool is versatile, for it allows documentation of the common presentation of uncommon diseases, uncommon presentation of common diseases, peculiarities of patient management (even when encountered by chance), and sets the stage for future research by promoting the development of new questions.^13,14 Even if the manuscript does not get published, the review of the literature required to support the case carries an educational value.

Scholarly activity adequately promoted and mentored in the academic setting,¹⁵ along with the emergence of new journals allowing paper-based or online publications of case reports, represents opportunities for the academic generalists to remain engaged with science advancement, and to inspire their trainees to follow their steps. 

According to Herbert Fred, MD, “to learn medicine, all you need is a patient, a medical library, and someone who knows more medicine than you do…Your knowledge will grow, but your educational journey will never end.”¹² 

Interested academicians will “know the patient through and through,”¹⁶ finding unique features in each of their patients. This uniqueness—the story of a particular disease in an individual patient, sometimes with a peculiar response to a treatment—is always worth telling.^13,17

Gabriel Aisenberg, MD, is an assistant professor of medicine at the University of Texas Houston Health Science Center and director of general medicine at Lyndon Baines Johnson Hospital, both in Houston, TX. 

References:

1.Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc.; 2003.

2.Young RA. Discussion: specialization—its value and abuse. Proc Royal Soc Med. 1949;42:1035-1039.

3.Cooper AR. The opportunities in specialization. J Natl Med Assoc. 1909;1(4):223-228.

4.Peeples L. Do specialist doctors make too much money? Reuters. October 25, 2010. www.reuters.com/article/2010/10/25/us-specialist-doctors-idUSTRE69O4RW20101025. Accessed June 3, 2014. 

5.Bodenheimer T, Berenson RA, Rudolf P. The primary care–specialty income gap: why it matters. Ann Intern Med. 2007;146(4):301-306.

6.Ferrer RL, Hambidge SJ, Maly RC. The essential role of the generalists in health care systems. Ann Intern Med. 2005;142(8):691-699.

7.Alpert JJ, Friedman RH, Green LA. Education of generalists: three tries a century is all we get!
J Gen Intern Med. 1994;9(Suppl 1):S4-S6.

8.National Center for Health Statistics. Health, United States, 2010: with special feature on death and dying. 2011. www.cdc.gov/nchs/data/hus/hus10.pdf. Accessed December 2014.

9.Kaczorowski J. Standing on the shoulders of giants. Introduction to systematic reviews and meta-analysis. Can Fam Phys. 2009;55(11):1155-1156.

10.Sedgwick P. Case-control studies: advantages and disadvantages. BMJ. 2013;348:f7707.

11.Sedgwick P. Retrospective cohort studies: advantages and disadvantages. BMJ. 2014;348:g1072.

12.Scheid M. The Best of Herb Fred, MD. 1st ed. Houston, TX: Halcyon Press. 2010.

13.Sudhakaran S, Surani S. The role of case reports in clinical and scientific literature. Austin J Clin Case Rep. 2014;1(2):1-2.

14.Pierson DJ. How to read a case report (or teaching case of the month). Respir Care. 2009;
54:1372-1378.

15.Basu R, Henry TL, Davis W, et al. Consolidated academic and research exposition: a pilot study of an innovative education method to increase residents’ research involvement. Oschner J. 2012;12(4):367-372.

16.Peabody FW. The care of the patient. JAMA. 1927;88:877-882.

17.Cabán-Martinez AJ, Garcia Beltrán WF. Advancing medicine one research note at a time: the educational value on clinical case reports. BMC Res Notes. 2012;5:293.