The cardiology literature is filled with randomized, controlled clinical trials (RCTs), some "mega," some not. The calculation of a journal impact factor is heavily influenced by the publication of the results of these trials, and there is often great fanfare at the time of the major meetings when those highly anticipated Late Breakers are presented and simultaneously published in the New England Journal of Medicine or JAMA.
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We seem to cite these large studies in our everyday practice: "As the RALES study showed ..." or "... as demonstrated in the RE-LY study ..." Our fellows know "trials speak" though cataloguing all the inclusion criteria, exclusion criteria, primary end points, secondary end points, P values, etc, is rather daunting.
The TIMI family of studies is now up to 57 and it would likely take someone like Raymond Babbitt (Dustin Hoffman in Rain Man) to recall the results of all of them.
So where does this leave the anti-RCT, the case report? As I tell my fellows, case reports are difficult to publish, and even case series can be a challenge.
I am convinced, however, that there is a role for the simple, straightforward "show and tell" that case reports often resemble. After all, we see one patient at a time, and that’s what case reports are all about. They can make you think about your own patient experience. Have you seen that phenomenon before? If so, what happened? If not, should you be thinking about it?
Medicine does not progress by anecdotes, but we can still learn from them. The caveat, of course, is that the path to bad medicine is paved with case reports. Recall the old line about certain unnamed surgical colleagues and how their practice evolves: "One is a case report, two is a series, and three is adoption in the OR."
We won’t go that far, of course. But when confronted with a choice between perusing some case reports or dissecting the latest 40,000+ patient study, I admit to enjoying the former a lot more than the latter. Does that mean I’d rather read the sports section over Dostoyevsky? I’ll give you the answer but only after TIMI 100 is published!
Dr. Paul J. Hauptman is Professor of Internal Medicine and Assistant Dean of Clinical-Translational Research at Saint Louis University and Director of Heart Failure at Saint Louis University Hospital. He currently serves as an Associate Editor for Circulation: Heart Failure and blogs while staring out his office window at the Arch.