Dermatology Launches the ‘Evidence-Based Case Report’ Section

Abstract

Accessible online at: www.karger.com/journals/drm Dermatologists tend to build up their expertise as a series of anecdotes. The visual features of a case stick in our minds so that we are able to recognize them in a new patient. Astute clinical observations are still fundamental to describe new disease entities and to raise new hypotheses concerning disease causation, including the effects of medical interventions. On the other hand, we all know that anecdotal experience is unrepresentative of the average case and thus a potentially biased influence on clinical decisions. The evidence-based approach to clinical decision making is often incorrectly held to rest on the assumption that clinical observations are totally objectivable. Actually, clinical decisions are usually driven by an amalgam of evidence and judgement and the ‘clinical method is an interpretative act which draws on narrative skills to integrate the overlapping stories told by patients, clinicians and test results’ [1]. Although there are certainly ‘wrong’ answers to particular clinical questions, it is often impossible to define a single ‘right’ one that can be applied in every context. Evidence-based medicine acknowledges that there is an art to medicine as well as an objective empirical science. It aims at integrating medical research with clinical practice in the most efficient way. Evidence is usually obtained by aggregating results of several comparable cases. The generalizable truth pertains to the sample, not the individual participants and is expressed in the language of probability (benefits and risks). On the other hand, the art of selecting the most appropriate intervention for an individual patient is acquired largely by the accumulation of ‘case expertise’. Many difficulties can be encountered when trying to apply to an individual patient the results of clinical research including the lack, poor quality or irrelevance of clinical research itself, and the existence of conflicting results. Evidence-based case reports [2] have been proposed as an educational strategy to help clinicians develop the art of using research evidence in clinical practice. An evidence-based approach usually follows four stages: (1) formulation of a clear clinical question from a patient’s problem; (2) searching efficiently the pieces of evidence which allow to address the clinical question (in many cases it is represented by published studies); (3) critical appraisal of the evidence for its scientific validity and usefulness (i.e. clinical relevance); (4) implementation of useful findings in clinical practice by taking into account accumulated professional case expertise and the individual patient’s requirements and preferences. Some crucial aspects to consider when assessing the evidence are mentioned in table 1. Evidence-based case reports may be useful to identify important research questions which still lack a reliable answer and to promote a reflection on issues like research organization and implementation. They may also be useful to understand the basis of diagnostic acumen and professional case expertise [3]. Dermatology is proud to launch its ‘Evidence-Based Case Report’ section. An evidence-based case report should start by presenting a clinical situation and by identifying a problem, making explicit the decisional process