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How to write a scientific article – Part VI – writing case report
*Corresponding author: Prashant P. Tamboli, Head, Department of Research, Associate Professor, Department of Repertory, Dr. M. L. Dhawale Memorial Homoeopathic Institute, Palghar, Maharashtra, India. mldtresearch@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Tamboli PP. How to write a scientific article – Part VI – writing case report. J Intgr Stand Homeopathy 2020;3(1):8-12.
Abstract
Scientific publications are possible only after completing proper documented research work. Research is one of the important methods for ensuring that the homoeopathic discipline keeps growing. A case report is one type of research design; it can be conducted with minimal resources. Case reports are, therefore, valuable despite being at the bottom of the ladder in terms of scientific evidence. It allows a physician to share their unique clinical experience/s in a peer group. Experiences of using homoeopathic concepts in different clinical situations and widening the scope of homoeopathy can be shared through this method. Case reports provide an opportunity to train young physicians to learn observation skills and use the scientific method to convey valuable clinical experience/s. The CARE guidelines are the gold standard guidelines for writing a case report. A group of homoeopaths have recommended further modifications to these guidelines for writing homoeopathic case reports; these specific guidelines are termed the HOM-CASE guidelines.
Keywords
Homoeopathic case report
Homoeopathy
Case report guidelines
INTRODUCTION
Medical science believes in evidence-based medicine; homoeopathy is no exception. When one talks about incorporating evidence-based medicine in clinical work, it is commonly believed that one should present evidence gathered through a properly conducted research process. This would imply the use of a standardised methodology with predefined sample strength and results arrived through statistical verification. Although this is true, research provides several designs, each with their own purpose. Randomised controlled trials are considered to be the best design for showing the efficacy of medicine and therefore top the list of evidence-based reports. Case reports are at the bottom of the ladder, as they deal with a single case.[1] Nevertheless, case reports are considered the first step to demonstrate evidence-based medicine.
PURPOSE OF CASE REPORTS
Case reports are usually written for describing unique clinical experiences in terms of diagnosis, investigations or management. Some case reports convey observations related to specific subjects enrolled in randomised clinical trials. These observations may not be very relevant to the main study objective, but could open new ideas or variations that need further exploration.[2] Apart from this, case reports can be about experiences of treating cases where the clinical diagnosis is still not established, but the symptoms indicate the need for treatment.[3] Thus, a case report should be a unique experience that widens the scope for medical science; it can act as an eye opener. Homoeopathy being an individualistic science, we need to know the importance of writing homoeopathic case reports.
IMPORTANCE OF CASE REPORT FOR HOMOEOPATHY
Practicing homoeopathy is an art and science.[4] It is based on the principle of individualisation, meaning each case is unique. Moreover, each physician perceives the case in a unique way. Does this mean that each successfully treated case can qualify as a case report? The answer to this question is not simple. One should understand the difference between treating a case i.e., being a clinician, and identifying the uniqueness and reporting that clinical experience to the homoeopathic community, thus becoming a researcher. Case reports are based on accurate observations and finding the uniqueness in the case. Naturally, we can do so only after we know what is usual or natural. Uniqueness can manifest at multiple levels. It may be in terms of the method used for eliciting the data during case taking, highlighting the importance of documentation by developing special case records. Uniqueness can also be evident in the way the physician analyses the case. It could be deriving a specific meaning from the patient’s narration or highlighting the reasons for selecting a specific rubric. A case can also become unique when physician interprets the susceptibility in a particular way and plans the posology accordingly. The physician can explain his remedy understanding or their logic for differentiating from other remedies. Thus, asserting the uniqueness of a case is possible by studying the relevant literature and expressing one’s thinking on the basis of sound philosophy.
Further reasons why homoeopaths should write case reports are as follows: To increase the ability to observe the findings, understand the findings based on the philosophical framework and develop the ability to share the experience in a scientific way with fellow homoeopaths. Therefore, all homoeopaths must master the skill of sharing the experience with clarity, especially those who are in the academic field.[3] This process is similar to the homoeopath undergoing a prover’s experience during drug proving. If a homoeopath undergoes drug proving as a medical student, their ability to observe in an unprejudiced way and their ability to record observations accurately improve. They become more aware of the change in the susceptibility as per the changes in the expressions, which, in turn, make them more aware of the action of homoeopathic remedies. Similarly, when a homoeopathic physician tries to share their clinical experiences, they become more aware of their logical reasoning capacity, conceptual grasp on the philosophy and scientific attitude. For all these reasons, it is vital that the physician in training learns the fine art of writing case reports.
FOCUS OF A HOMOEOPATHIC CASE REPORT
The most important step is to identify the unique experience, which can be from any of the following areas:
Unique clinical presentation for a clinical diagnosis
Sharing these experiences helps understand the disease from the homoeopathic perspective. When the author was working on a research project on diabetes mellitus in 2002, many patients complained of only heel pain. At that time, the relationship of diabetes and heel pain due to calcaneal spur was not known. When this was considered as a concomitant symptom, the totalities created unlocked several cases. Later, a number of studies found an association between calcaneal spur and diabetes.[5,6] The possible reasons were identified as decreased ability of tissue repair and increase in reactive ossification in diabetes. Nevertheless, sharing such case reports would help the homoeopathic community.
Providing evidences for widening the scope of homoeopathy
Physicians have several clinical experiences where prima facie it appears that homoeopathy may not have any solution. However, homoeopathy is found to help in those cases. Sharing such cases will widen the scope of homoeopathy. Raveender and Banoth reported a case of acute paraphimosis with balanitis, where an otherwise surgical case was cured with homoeopathy. They shared the experience of prescribing two homoeopathic remedies alternately, along with photographic evidence.[7] This method of prescribing two remedies is not followed regularly, so such case reports may indicate the need or scope of such therapeutic intervention. Dr. Pal shared another interesting case of lacrimal gland tumour, needing surgical intervention, which was treated with homoeopathy.[8]
Providing evidences for scope of homoeopathy for aborting the diseases
Homoeopathic treatment is not necessarily dependent on diagnosis, which is an advantage, as we need not wait for establishing diagnosis to initiate treatment. This can abort the disease progression and prevent complications. Another case study by Tamboli and Broker describes a case of evolving transient ischemic attack (TIA) with the presentation of unilateral dissociated sensory deficit pattern.[9] The diagnosis of TIA was confirmed with relevant investigations such as MRI angiography, but the full effect on the body had not yet developed. Therefore, the disease was in the evolving phase. The case report shares how a proper clinical history and timely investigation helped in aborting disease progress. The report also describes how and why a series of remedies were selected using Boger’s approach. Sharing such cases helps in establishing the scope of homoeopathy in such acute emergencies. It also shares the application of philosophy in practice.
Philosophical explanation and use of repertory and Materia medica
Case reports can also highlight various philosophical aspects, importance of converting symptoms to rubrics, meaning of rubrics and peculiarities in Materia medica, all of which helped unlock cases. All such aspects will widen the knowledge of the homoeopathic community. Dr. Sharma shared a case report in IJRH demonstrating the use of repertory in solving a case of menopausal hot flashes.[10]
Until now, majority of the case reports published in scientific journals centre on demonstrating the effect of homoeopathic medicines in certain diseases or widening the scope of homoeopathy. Apart from this, there is a lot of scope for writing case reports highlighting various homoeopathic concepts.
Homoeopathic case reports can belong to the following categories
Unique clinical presentation – understanding clinical aspect through the homoeopathic philosophy perspective
Using modern investigative tools that give a diagnostic meaning to the disease presentation
Making homoeopathy more evidence based – providing advanced investigations for claiming the efficacy and safety of homoeopathy
Increasing the scope of homoeopathy in surgical cases or cases with congenital problems
Use of homoeopathy in aborting the disease process mid-way
Demonstrating the application of homoeopathic concepts such as philosophical repertorial approaches, miasm, susceptibility, posology and rare source of HMM, all of which throw light on an author’s unique understanding of the case.
GUIDELINES FOR WRITING CASE REPORT
A case report is an experiences shared by a practitioner in a specific field; in this case, it is homoeopathy. Case reports may be helpful in evolving further clinical care or therapeutic guidelines. While evolving the guidelines, the author should give sufficient background and justification so that the reader is free from biases. This is possible if all the details of the case are shared, which allows readers to assess the effect independently. Therefore, a group of experts evolved the CARE guidelines for writing case reports. Numerous authors, journals and publishers have adopted these guidelines.[11] van Haselen, using the Delphi technique with a panel of 19 homoeopathic experts, suggested modifications in the CARE case report guidelines for writing homoeopathic case reports. He has recommended using these HOM-CASE guideline extensions to improve the quality of homoeopathic case reports.[12]
FORMAT OF CASE REPORT
Scientific articles are written in the Introduction, Methodology, Results and Discussion format. However, case reports require certain modifications. The various sections of the basic standard format are reproduced below.[13]
Title
Abstract
Keywords
Introduction (background)
Case presentation
Discussion
Conclusions
Patient’s perspective
List of abbreviations
Conflicts of interest
Acknowledgment
References.
In addition to the above, the publisher may need the following:
Consent
Author’s contributions.
This journal, the Journal of Integrated Standardized Homoeopathy, has provided guidelines for writing case reports. The reader can refer https://jish-mldtrust.com/for-authors/
The following is a brief explanation for each heading.
Title
The title should be short and crisp. It should represent the author’s experience or the purpose of writing the case report.
Abstract
This is a crucial section of the article; often, this is the only part available to readers online and influences their decision to read the rest of the article. The abstract should, therefore, be a concise yet comprehensive summary of the article, including presentation, diagnosis, treatment and follow-up. The abstract should convey the importance of the case report and why this particular case should be reported, along with the author’s learning. Abstracts are usually not more than 250 words.
Keywords
Keywords are used for indexing and retrieving the article. Ideally, it should be the Medical Subject Headings (MeSH) terminology. Most of the indexing software like PubMed gives the list of such terminologies. However, all terminologies used in homoeopathic philosophy, such as miasm, are not listed. Homoeopathically oriented papers may write such key words in addition to the standard MeSH terminologies. Usually, three to five keywords are provided; they should represent the main experience or purpose of the case.
Introduction (background)
The introduction should elaborate on the purpose of the case report, such as sharing unique presentations or treatment strategy. In cases where treatment is the focus, references of the usual therapeutic practices can be provided; if the case has another purpose, other factors such as normal disease advancement if the disease is not treated in time can be elaborated. A limited review of the literature can be added. However, a detailed review is not expected here.
Case presentation
This is the most important section of a case report. Adequate details of the patient without revealing the identity should be provided. The progression of the case should be presented in a chronological order, with details regarding each point. Proper evidences in terms of investigations, treatment history and personal history should be provided. Actual intervention in terms of treatment, the process of finalising the treatment and the subsequent changes in the patient should be given. The details enable the reader to evolve their own assessment of the matter. It is important to remember that one should provide all the data related to the main purpose of the case presentation. Unnecessary details should be avoided.
Depending on the purpose of the case report, the relevant aspects from the following list can be added and expanded, as mentioned in the guidelines for writing the case report.
Patient information
Clinical findings
Timeline
Diagnostic assessment
Analysis and synthesis
Totality and processing
Susceptibility assessment
Planning and programming
Therapeutic intervention
Follow-up and outcomes.
Discussion
This section is for the author to share the reasons or their understanding of the case. The author can compare their findings of the case with similar cases published or shared on various platforms. This will help in developing a logical explanation and highlighting the uniqueness of the case experience.
Conclusion
This section should be to the point. It should give clear conclusions from the important observations of the case. It should clearly state the relevance of the case to homoeopathic science.
Patient’s perspective
This is not mandatory. However, in some cases, it is important to add the patient’s experience as it gives an idea about what the patient experienced and their appreciation of the changes that may have occurred. This section may not add much scientific value. However, in situations where evidence is not possible, the patient’s own experience may be useful. For example, if the author wants to highlight that the improvement in the patient started within 4 h of the treatment. There may not be any investigations available to support such a claim. In such cases, the patient’s experience to support that claim may be used. However, one must remember that the testimony is not sufficient to demonstrate complete cure and it should be supported with proper investigations. Care should be taken that only the relevant experience should be written in the patient’s own words and the patient’s identity should not be revealed.
List of abbreviations
This section should be used to avoid confusion due to the use of abbreviation. Sometimes, the author may think that some abbreviations are routinely used and hence do not need to be explained. However, one must remember that we are writing for a global audience; abbreviations and acronyms may have more than 1 meaning.
Conflicts of interest
The author should declare that there is no financial or any other conflict of interest. It is important to state if any sponsorship was received for this work or presentation.
Acknowledgment
The author should acknowledge contribution of all those who have helped in this process but did not meet author criteria.
References
References indicate that the author has studied the topic in depth. They also acknowledge the work done by others on the same topic. Accurate listing of all the required references is, therefore, essential. This allows the reader to undertake further reading in the subject area. References should be formatted as per the style required by the target journal.
Consent
A statement should be provided that all the necessary permissions from the patient were obtained before publishing the case report. Written consent is always advisable. Consent is mandatory, especially when photographs are published in the manuscript.
AUTHOR’S CONTRIBUTION
If more than one author has worked on the manuscript, it is preferable to state the specific contribution of each author. It is considered that the first author has made maximum contribution to the knowledge generation process.
CONCLUSION
Case report is a very important and basic method of generating evidence-based knowledge
It brings out the uniqueness of the homoeopathic science
It is useful for demonstrating homoeopathic concepts and expanding the scope of homoeopathy
It may be useful for training young physicians in the skills of observations and descriptive writing.
ACKNOWLEDGMENTS
I sincerely thank Mrs. R. M. Belsare for giving me the opportunity to write this article and Dr. Kumar Dhawale for his valuable guidance.
Declaration of patient consent
Patient’s consent not required as there are no patients in this study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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