As a dog returns to its vomit and an alcoholic to his whiskey so an old editor will return to editing. You might think that after 25 years at the BMJ and writing a book slamming the whole idea of medical journals I might have had the decency to remain in obscurity. But no: I'm back two days a month editing Cases Journal, an open access journal that aims to publish tens of thousands, even thousands of thousands, of case reports each year. We will publish anything that is authentic, understandable, ethical and “complete enough.” Our bias is to publish, and your report doesn't have to be “original” or “important” because we- radically- believe that every case is original and important.
This new journal is an example of what Science magazine has called Science 2.0. Science 1.0, which remains hugely important, is reductionist and does all it can to limit variables. Randomised trials are excellent examples of Science 1.0. But real life- as every doctor knows- is full of conflicting variables. Real life, to be pretentious, is “non-linear.” Science 2.0 attempts to use the networking power of the web- like My Space, Facebook, You Tube, or Twitter- to create new and useful knowledge.
Consider the classic problem of comorbidities. Some 17 million people in Britain have a chronic condition, and 40% of them have more than one. American data show that patients with three or more chronic conditions account for 89% of Medicare spending- and patients with five or more account for 66%. Yet most guidelines on treating patients with chronic disease don't mention comorbidities- which is not surprising because they are based on randomised trials that excluded such patients. Mike Rawlins, chairman of the National Institute for Health and Clinical Excellence, has shown how following guidelines for individual diseases can leave patients with several conditions on a dozen drugs- many of them contraindicated.
We will build a database of all our cases reports, and we will include reports from our sister journal, the Journal of Medical Case Reports, and other journals. Plus we will ask all those who submit a case report to update us on the case each year. A patient or his or her doctor will thus have a good chance of finding a patient- and eventually several- who is exactly like him or her, perhaps with four conditions and a weird and wonderful history. They can also find out what happened to those patients. Such “evidence” won't make the decision on what is best to do- but nor does evidence from randomised trials.
But there are other reasons for creating a journal that will publish almost any case report. Patients will soon be able to submit their own cases, and we urge doctors to submit cases with patients whenever possible. We will tap the “wisdom of crowds,” and any doctor (and eventually patient) will be able to ask a question like: “Has anybody else seen a patient who experienced the most disgusting, metallic smell while having radiotherapy to the brain?” Plus we are democratising medical publishing. The humblest doctor in the trenches can submit his or her case report and be in PubMed within days.
You'll observe that there's something of an anarchic feel to this new journal, one of its main delights. Some will be attracted, some appalled, but we are hoping too for some literary excellence. I know that there are doctors out there who may be budding Chekhovs or Freuds, who will be able to write case reports that will delight, amaze, and teach us. Finally, it will allow doctors to profit from their own illnesses. I've already written up my “Beijing cough,” and I plan to plot my decline- no matter how rapid- in the new journal. Join me.
Author’s competing interests: RS is editor-in-chief of Cases Journal and author of The Trouble with Medical Journals, published in 2006. The text of this article was originally rejected as a blog posting by the BMJ, which RS edited from 1991 to 2004.
