The Multiple Evidential Roles of Clinical Case Reports

This talk is being held as part of the History & Philosophy of Evidence-Based Health Care module which is part of the MSc in Evidence-Based Health Care. Members of the public are welcome to attend.

Brian Hurwitz is D’Oyly Carte Professor of Medicine and the Arts in the Department of English. He is a medical practitioner affiliated to the Division of Health and Social Care Research, King’s College London, directs the Centre for the Humanities and Health and is a member of the Steering Advisory Board of the Centre for Life-Writing Research at King’s.

There is a longstanding view that clinical case reports are one of the chief means by which the findings and experiences of health care practitioners are shared with others, and this year The Lancet set out plans to publish longer, more detailed case reports, together with expert commentaries on them. Although the philosopher of science, Ian Hacking, has cautioned that ‘[f]airy tales create fairy causes’, The Lancet announced: ‘Throughout history people have interpreted the world around them and passed on lessons learned through myths, fairy tales, parables, and anecdotes. Medicine is no different… ’.

Typically, modern cases are remarkably terse accounts of problems and predicaments in an individual’s life written from distinctively clinical viewpoints. Standardly, they pay close attention to the visceralities of illness experience – altered appearances, behaviours and functions – that are open to direct inspection. They also feature symptoms such as pain, nausea, altered sensation, mood and loneliness which are more or less private experiences to which only the patient has direct access, ‘insiderphenomena’ which to feature in case reports are dependent on the capacities of patients convincingly to convey inner states.

Archie Cochrane once published a case in which loneliness was the central feature. He recognised this only by accident, as a result of an instinctive human gesture he made towards a dying man. Loneliness turned out not only to be a heart-rending aspect of his situation but the explanation for what happened next. In addition to describing situations and sequences of events and findings case reports seek to explain them, and Cochrane later wrote about how this case set him on a new path. His own life-long medical conditions, together with ‘lessons learned’ from this case, influenced his academic work and what he advised others to study.

Collectively clinical case reports constitute a huge repository of medical experience. This talk will scrutinise their shape, salient features, and the nature of the hindsight from which they are composed, filtered for coherence, and turned into second order accountsof encounters, observations and reasoning about a patient or series of patients. It asks what case reports are good for and what kinds of knowledge they embody.

Ian Hacking, Rewriting the soul. Princeton: Princeton University Press, 1995.
Philippa Berman, Richard Horton, Case reports in The Lancet: a new narrative. Lancet 2015;385:1277.
A. L. Cochrane, One man’s medicine: the autobiography of Archie Cochrane. London: BMJ Memoir Club, 1988.