1. Case Study approach to Healthcare Rakesh Biswas MD Deputy Editor, BMJ Case Reports
Original file -
Speech delivered on June to KMC Manipal, India, students and faculty through web-conference

2. Who is the prime beneficiary of Medical education?
Student
Faculty
Patient
Practitioner
Good afternoon faculty colleagues, students and everyone there at KMC Manipal. I began my teaching career at Manipal, Pokhara more than a decade ago and it is good to note that many of you who i began my career with at that time are currently full professors in KMC. It is indeed a great feeling to be able to get in touch with all of you through this web-conference.
The first slide looks like an MCQ but this is just my way of presenting the ‘problem statement’ for today’s discussion as this may allow us to explore further ‘why’ should we at all think of ‘case reports.’
Now if the answer to this MCQ is not too obvious the hint that i would like to drop is: Three of the 4 choices that you see on screen are perhaps physically present right here in this gathering and the one that is not is the answer to this MCQ.
Most of us here: students, faculty, practitioners benefit from Medical education in one form or the other BUT by and large Medical Education has evolved as an institutionalized discipline primarily for the patient beneficiary.
Our lives in any medical institution hovers around our patient beneficiaries and whatever we do in our institutions is always necessarily geared toward the needs of these primary beneficiaries. So the re-phrased problem statement here is: What would be the optimal way for most Medical Institutes to provide the best care for their primary beneficiaries in all that they do? One solution that we would like to propose as the statement of a hypothesis is: “A Patient centred Case-Reports mindset can lead to an ideal learning ecosystem and consequently better patient-care in any medical institution willing to adopt it.” In the next few slides i shall take you on a journey that may encourage you to try and prove this hypothesis in your own institution. I move to my second slide...

3. Why Case Reports? Is it research?
This is my second slide...and one of the big questions about case reports is what kind of a research is it? Now, current day research gives more value to counting (such as counting the number of fruits in a tree without tasting the actual fruits or the number of people in a clinic without going into the details of their lives) and consequently most of our research orientation is quantitative. While this is really a good thing it may not encourage us to think, wonder and explore at phenomena or events we encounter in our day to day experiences with patients.
This is where we require a case-reports mindset born out of a natural inquiry and thirst for learning that is actually inbuilt in all humans and ‘research’ is nothing but shared learning. In the past there were fewer platforms for sharing our learning experiences with the world but with the advent of the internet there has been an explosion in shared learning.
I am particularly reminded of a very enthusiastic faculty in Physiology (also from Manipal) who rapidly mastered the art of case-reporting and i would always make it a point to have him on our rounds whenever there was an interesting patient not only to help us publish the case (with him as a first author) but also because of the tremendous value addition it brought in terms of bringing vertical integration to our medical education curriculum.
All learning in our medicine curriculum (medicine meaning the entire MBBS) can be initiated through a patient centred inquiry and few things can be more fulfilling than this form of medical learning.

4. What can Case-Reports do for us?
Will it fetch the Nobel Prize?
Can it better patient care?
My third slide...Case Reporting is always the beginning in clinical research. Just one report may not fetch you the Nobel prize but it may be able to raise a prize winning research question and that question can become a game changer in medicine. 
Some of you may be intrigued with the hypothesis mentioned in the first slide. I mean why should a “case-report mindset lead to better learning and patient-care?”Well one of the possible reasons is that: Most faculty would not take any chances with their cases if they were to be always made aware that whatever they do for their case would eventually get published and shared with the world. No faculty would want to look as if they had not done the ‘right’ thing for their patients.
But then does this mean that there will be a rise in needless investigations where patients would have to pay the price of making a worthier case report? NO! Simply because that is not the RIGHT thing to do for your patient. Health professionals in all institutes can just keep working with whatever resources they and their patients can manage and still frame a case report worthy of publication often through a portrayal of the multi-faceted explorations of complex issues in the patent’s real-life setting. Now, I guess the last statement is particularly heavy so i have a slide coming up next to clarify that. 

5. This is my 4th slide...This pub-med abstract of a review of the case-study method (the full text is available online) is just to point out the source of my statement about the case report being a potential “portrayal of multi-faceted explorations of complex issues in the patent’s real-life setting.”
Now how is a case study different from a case report or are they same? “The Case-Study method is essentially a qualitative research tool and has evolved from a disease-focused case-report approach to a modern day multifaceted approach that does not look at just the disease from a point of view of a clinical expert but also looks at the patient’s values and preferences and many believe that patient values are an important but often overlooked component of evidence based practice.
This is one of the reasons BMJ Case Reports has incorporated a ‘Patient’s perspective’ feature that gives you the opportunity to invite your patients to write about themselves and share their innermost thoughts with the world (anonymously and with informed consent solely as per their wishes).

6. Case-Reports as a tool to integrate Medical Education and Practice?
How?
Why?
What?
We move on to our 5th slide...I believe all institutions around the globe should grab the opportunity to document their day to day patient centred learning experiences in this Pubmed Indexed Case Reports platform in the broader interest of patient care. I can see some of you in KMC, Manipal are already into this process as you have already published in BMJ Case Reports. Globally there are cases published in this Pub-med indexed platform today and it keeps growing everyday. Most patients with illnesses lasting more than a month can be published as each and every patient has certain illness characteristics or (multiple facets) that are unique and worthy of shared-learning. The trick is to cultivate an approach that enables us to identify those facets in most of our patients. 
One way to go about cultivating the case-study approach would be to also take advantage of web based platforms where you can actually share your raw cases with others (after having taken informed consent and authorization from the patient and taking care to remove patient identifiers as per available guidelines). This web based sharing will enable you to obtain further insights on how to unpack the multiple facets of your case and build up a more meaningful discussion in your report.
We are already running such a platform in collaboration with the BMJ Case Reports where we encourage medical students and faculty to post their cases (after appropriate authorization from their patients) and learn asynchronously together with other online medical students and faculty present in our platform. There are mechanisms underway to integrate it with automated search algorithms where simply posting your case automatically brings up similar cases from the BMJ Case Reports database.
We have been trying to develop this online learning ecosystem over the last few years in our bid to integrate medical education with practice and we shall be happy for other institutes to join in and help to spread this model further in the best interests of the primary beneficiaries of medical education (aka patients). 

7. This is the last slide and it is to illustrate similar recent endeavours globally and the paper you see here was published recently in BMJ Case Reports by faculty colleagues from the Molecular Gastroenterology unit of Sheffield University. Their paper illustrates to a certain extent whatever i have been trying to put across in the previous few slides.
The authors in this BMJ case report identified a substantial body of patient data surrounding a potential therapy for their own patient’s condition on social media sites and performed a systematic analysis of the internet-based data surrounding their patient’s problem.
i won’t say this article doesn’t have HOLES but the good part about the report is that the authors have made a beginning in manually and qualitatively mining the rich patient centred data that already exists online and this technique if scaled judiciously and collaboratively has immense potential to benefit our individual patients.
THE BOTTOMLINE for the entire presentation today is that if health professionals are not just focused on the disease and also consider the patient as a person and taken in the other dimensions of the person’s life requirements they would be able to better publish their case-reports as a valuable addition to the literature.
You will notice that in this address i have not answered more burning-practical questions such as “what is the impact factor of BMJ Case Reports?” or “Will publishing in BMJ Case Reports count for faculty promotions?” etc because i have simply focused on what YOU can do WITH Case-Reports rather than what Case-Reports can do for you. I will be happy to take all these burning practical questions over the next 15 minutes although i can’t promise to have an answer to all of them. Feel free to me if you miss out on your questions in this live session. I have put my address at the end of the previous slide. Thanks for listening.

8. Thanks for listening!