Introduction

Clinical case reports have been an essential medium for disseminating medical knowledge since the inception of medicine itself. Tracing back to Hippocrates' era and perhaps even to ancient Egyptian medical writings, these reports have played a pivotal role in the medical literature [1]. They are instrumental in sharing clinical experiences and bringing to light significant scientific findings that could be missed in clinical trials. A notable example is James Parkinson's 1817 description of "shaking palsy," which was crucial in recognizing Parkinson's disease [2]. Similarly, the early observation of Kaposi's sarcoma in a young homosexual man significantly contributed to the discovery of acquired immune deficiency syndrome [3]. Moreover, case reports have played a critical role in identifying adverse effects. A significant case is the identification of a link between fenfluramine and dexfenfluramine with primary pulmonary hypertension. Originating from case reports, this discovery led to more in-depth research and eventually caused the withdrawal of these drugs from the market [4,5].

The purpose of case reports is to record on paper new findings gathered during clinical practice and disseminate the information to those in the medical profession. Case reports can be on a variety of topics. They could be reporting from a previously unknown symptom or new complications for a known disease to information on a new side effect for a common medical procedure or a new type of therapy for a common disease. Generally, the content in case reports usually contain descriptions of the symptoms, diagnostic procedures, and details on treatment [6,7].

Case reports offer numerous benefits. Firstly, they provide readily accessible information. Contrasting with the complex methodologies and extensive data verification processes typical of scientific research, the data in case reports originate directly from clinical practice. Daily clinical operations and outpatient visits yield first-hand, unprocessed data. When clinicians are meticulous and observant, this data can be effectively compiled into case reports, identifying instances worthy of documentation. Significantly, case reports exert a substantial influence on subsequent medical literature and potentially on clinical practice, with many prompting further clinical trials [8].

Challenges and Solutions

In the current digital era, characterized by the proliferation of paperless journals, case reports are witnessing a resurgence, particularly within open-access platforms [6,9,10]. However, a contrasting trend is evident in traditional academic journals, where case studies are often positioned at a lower tier in the study design hierarchy, coupled with an increasing reluctance to accept such submissions [11–13]. This shift, observable across various academic disciplines, is influenced by a multifaceted array of factors.

The upcoming analysis aims to dissect and elucidate eight key elements that are catalyzing this shift in academic publishing paradigms. It is imperative to recognize and understand the multifaceted nature of this phenomenon. The publication of case reports, historically a staple in academic discourse, now confronts a maze of challenges and diverging viewpoints.

A comprehensive and critical assessment of these underlying factors is vital. Such an evaluation will not only reveal the nuanced intricacies that govern the publication of case reports in contemporary scholarly journals but also propose a holistic approach to decipher and effectively navigate these complexities. This endeavor is crucial for academicians and publishers alike, seeking to understand and adapt to the evolving landscape of academic publishing in the digital age.

Focus on Original Research
In the dynamic landscape of scientific publication, there is a growing emphasis on research that offers broad, generalizable insights, often leading to a preference for original research and systematic reviews. These types of studies are favored for their potential to significantly enhance the collective knowledge base in various fields. Conversely, case reports, which typically focus on unique or rare occurrences in individual patients or unusual clinical presentations, face challenges in garnering similar interest due to their limited scope and narrower applicability [11].

Despite this, the unique nature of case reports is indispensable in medical literature. They frequently shed light on rare conditions and novel treatment methods, sparking further research and innovation [13,14]. The American Medical Association, marking its 150th anniversary in 1985, selected and reissued 51 groundbreaking papers from the Journal of the American Medical Association. These papers were pivotal in transforming both medical science and clinical practice. Notably, five of these seminal publications were case reports [15].

To address this contrast, it is proposed to establish dedicated sections in journals specifically for case reports. These sections would highlight the most educationally impactful and innovative cases. The aim of introducing dedicated sections or special editions for case reports is not to create a hierarchy but to acknowledge the importance of these contributions. This approach would ensure that these valuable insights are given appropriate attention, while seamlessly integrating with other research. Furthermore, the idea of special editions or forming partnerships with platforms focusing on case studies is recommended. This would ensure that these crucial contributions are not overlooked, striking a balance between general applicability and the recognition of rare, yet essential insights.

It is notable that the qualities of case reports act as a double-edged sword. Predominantly focusing on outlier cases, they risk diverting attention and resources from more prevalent medical conditions affecting the broader population. However, such a diversion is not inevitable. Case reports often lay the groundwork for new research directions and spur innovation. By acting as catalysts, they ignite curiosity and promote further inquiry, potentially benefiting a wide range of medical conditions, from outliers to those more common.

Impact Factor Concerns
The impact factor of a journal is a measurable indicator of its significance in the academic world. It calculates the average number of times articles from a specific journal, published over a two-year span, are cited by other academic papers and scholarly publications in the subsequent third year. Case reports typically garner fewer citations than other types of research articles, such as original research or reviews [6,16]. This phenomenon stems from the inherently focused and unique nature of case reports, which often limits their appeal to a broader academic audience. Consequently, journals might opt not to publish them, aiming instead to bolster or maintain their impact factor. An increase in the impact factor of a journal not only amplifies its prestige but also serves as a magnet for higher-quality submissions, thereby enhancing its visibility and stature in the academic landscape.

While case reports are typically cited less frequently than other forms of research articles, notable exceptions exist [6,16]. Furthermore, the number of citations an article receives does not always reflect the extent of its readership or the degree to which its findings have been disseminated in the mainstream media [6]. Solely relying on citation metrics, such as impact factor, to evaluate the significance of academic articles can be myopic. Case reports are vital in medical education and in identifying clinical anomalies or innovative treatments. Their contribution to inspiring new research directions and informing clinical practice cannot be fully appreciated through traditional citation metrics.

To embrace a broader view of value in scientific communication and diminish the influence of impact factors, efforts have emerged to introduce alternative metrics that evaluate the educational impact, clinical relevance, and inspirational value of case reports. These could include measures of readership engagement, educational usage, and citations in clinical guidelines or policy documents. Recognizing that metrics are diverse and complex, Nature journals have started incorporating a range of citation-based metrics in addition to impact factors; similarly, the American Society for Microbiology journals have ceased to highlight impact factors on their websites [6]. Journals could also survey clinicians and educators on the utility of case reports in their practice and teaching. By diversifying evaluation criteria, the academic community can more holistically assess the value of case reports beyond just citation counts. Research databases indexed by Medicine/National Institutes of Health are frequently curated to maintain the quality of the publications they include [6]. This underscores the importance of prioritizing the improvement of the content quality in case reports rather than solely emphasizing the impact factor.

Critics may suggest that although metrics such as readership engagement and educational application provide a broader perspective, they might not adequately quantify the direct effects of case reports on patient care and scientific advancement. These indicators, however, are crucial for illuminating the practical impact of case reports in clinical practice and medical education, areas often neglected in citation-based assessments. By integrating these varied metrics with traditional citation counts, a more thorough evaluation of case reports is achieved, acknowledging their extensive influence in the scientific and medical realms.

Space Limitations
Traditional print journals have finite space for publishing articles, making the selection process highly competitive. Even in the digital realm, there is a premium on the amount of content that can be effectively managed and presented. Case reports, while valuable, often provide insights into singular events or observations and may not be as impactful as larger studies or comprehensive reviews. Therefore, journals might prioritize research that contributes more substantially to the field, offering broader insights or conclusive findings over the detailed description of a single case, regardless of its uniqueness or educational value [17].

The transition to digital publishing presents an opportunity to reconsider the limitations traditionally associated with print media, such as space constraints. Traditional print journals can effectively leverage digital platforms to incorporate case reports, offering select articles exclusively online. This digital approach facilitates the publication of a greater volume of research than is feasible within the confines of a print edition. Importantly, it expedites the dissemination of findings, a crucial element in dynamic fields like medicine and science. Furthermore, digital platforms enable the inclusion of multimedia elements, such as videos, audio commentary, and interactive figures in articles, thereby significantly enriching the academic content and enhancing reader engagement and comprehension. In conclusion, digital platforms can accommodate a much larger body of content, including case reports, without the physical limitations of print journals. Thus, the exclusion of case reports due to space constraints is less justifiable in the digital age.

Preference for Large-Scale Studies
There is an increasing trend in the scientific community towards valuing large-scale studies, systematic reviews, and meta-analyses over case reports. These types of studies are often seen as more scientifically robust, providing stronger evidence through larger sample sizes and comprehensive analyses. They also offer broader insights and generalizable findings that can significantly influence practice and policy. In contrast, case reports, which typically describe individual or rare instances, may not provide enough evidence to influence broader clinical or research practices [18]. This shift in preference reflects a broader trend in scientific research towards prioritizing studies that can offer more substantial and wide-reaching conclusions.

While large-scale studies are important for establishing generalizable findings, case reports offer depth and context to these findings. They provide real-world examples of how broader trends manifest in individual patients and can reveal exceptions that challenge or refine existing knowledge [19]. Excluding case reports creates a gap in the academic record, where the nuanced and human aspects of medicine may be overlooked.

Journals are advised to publish case reports and larger studies concurrently, offering a more holistic perspective on medical research. Journals may establish specialized issues or sections that showcase case reports relevant to the subjects of recent extensive studies. This approach not only enriches the academic discourse but also helps in bridging the gap between theoretical research and clinical practice. Additionally, journals might prompt authors of large-scale studies to cite pertinent case reports as exceptional instances, effectively merging the in-depth insights of individual cases with wider research trends.

Promoting the inclusion of case reports in broader studies is beneficial, but safeguarding against selective and biased case selection is crucial. Journals should formulate guidelines for authors, underscoring the need for objective citation of relevant case reports, irrespective of whether they corroborate or contradict the study's results. Ensuring transparency in the citation process with explicit justifications for each inclusion can help mitigate bias. Additionally, peer reviewers and editors ought to meticulously examine the selection of case reports during the review phase. The involvement of independent experts, especially in instances of suspected bias, adds another layer of impartiality. Through strict editorial oversight and adherence to ethical citation practices, journals can achieve a harmonious balance between the contributions of case reports and larger studies, thereby preserving the integrity of research.

Quality Control Issues
The peer review process is fundamental in ensuring the quality and credibility of published research. However, the unique and often highly specific nature of case reports can make it challenging to find suitable peer reviewers who are experts in the scenario described. Unlike more standardized research articles, case reports may lack certain benchmarks and criteria typically used in the review process, such as statistical analysis or methodological rigor common in larger studies. This can lead to challenges in assessing the quality and reliability of these reports, making them less attractive to journals that aim to maintain high academic and scientific standards [20].

Nevertheless, the unique nature of case reports should not be seen as a barrier but as an opportunity to diversify and specialize the peer review process. Specialized review for case reports acknowledges their value and ensures they are assessed by appropriate criteria, rather than being judged by standards more suited to other types of research.

To resolve the challenges, journals could implement a specialized peer review system for case reports, engaging experts versed in this format. There is a concern that a distinct review process might marginalize case reports within wider academic discussions. However, the primary objective of such a system should be to elevate the recognition and quality of case reports, not to segregate them. This specialized review mechanism is intended to supplement, rather than supplant, the conventional peer review process. Maintaining the impartiality of specialized reviewers is essential. Clear selection criteria and measures to avoid conflicts of interest are crucial. Additionally, rotating specialized reviewers and ensuring a breadth of expertise are strategies that can further reduce the likelihood of bias.

Training programs or guidelines can be established to assist reviewers in assessing the quality and relevance of case reports. This could include evaluating the uniqueness of the case, the clarity of presentation, and the ethical aspects, such as patient consent and privacy. Establishing a dedicated editorial board or a review panel specializing in case reports can ensure that these submissions are evaluated fairly and constructively, enhancing their quality and impact.

The feasibility of journals investing in specialized training for reviewers, considering their existing substantial workload, is debatable. This situation could lead publishers to face difficulties in resource allocation and persuading reviewers to participate in training initiatives. To mitigate these issues, publishers can employ a variety of strategies. These might involve the allocation of specific resources, collaboration with subject matter experts, and the introduction of adaptable, optional training modules. Recognizing the efforts of reviewers and underscoring the training's benefits, such as enhanced peer review effectiveness, can encourage engagement. A phased approach and clear articulation of the program's merits are crucial for gaining reviewer support. Tailoring the program based on feedback underscores a commitment to improving the reviewer experience. Additionally, publishers could establish mentoring and peer support networks to cultivate a community among reviewers. In essence, motivating reviewers to undertake training entails offering incentives, acknowledging their critical role, and ensuring program adaptability, while continually refining the initiative to serve both the reviewers and the integrity of scholarly publication.

Increased Volume of Submissions
The rapid expansion of the scientific community has led to an increased number of submissions to academic journals. This surge challenges journals in efficiently managing and reviewing these submissions. Consequently, many journals have revised their selection criteria, showing a preference for articles with broader impacts, like extensive studies or thorough reviews, rather than more specialized case reports. Such strategic selectivity is designed to preserve the journal's quality and relevance in the densely populated field of academic publishing.

While journals face an increasing volume of submissions, selectively excluding case reports can lead to a homogenization of published content, where only certain types of research are valued. This not only limits the scope of academic discourse but also potentially overlooks important clinical observations and innovations presented in case reports.

Therefore, it is crucial for journals to implement a selective strategy that prioritizes the publication of high-quality, clinically relevant case reports. This could involve setting specific criteria for case report submissions, such as requiring them to demonstrate exceptional educational value, describe novel treatments or pathologies, or provide significant insights into clinical practice. 

Additionally, journals could allocate a fixed percentage of their publication space to case reports, ensuring a balanced representation of different types of research. This approach would maintain the diversity of academic content while managing the volume of submissions effectively. In considering the allocation of publication space to case reports, publishers may identify inflexibility as a potential issue with setting a fixed percentage. To address this, journals could adopt a dynamic approach that allows for adjustments based on the volume and quality of submissions. This approach offers a range of flexibility within the predetermined percentage, enabling journals to adapt to the actual quantity and quality of the received submissions. Implementing such a strategy provides the necessary leeway to modify the space allocated to case reports in response to the real-time influx and standard of submissions. Ultimately, this method empowers journals to achieve a balanced presentation of diverse case reports while upholding high editorial standards, accommodating variations in the quantity and quality of submissions over time.

Shift in Research Focus
The focus of scientific research is continually evolving, often shifting towards studies that provide quantifiable and statistically significant data. These studies are perceived as offering more robust and conclusive insights compared to anecdotal or single-case studies. As a result, journals may align their publication strategies with these research trends, favoring articles that contribute to the development of evidence-based practices and policies. Case reports, while valuable in highlighting unique or rare cases, may not fit into this paradigm of research that emphasizes reproducibility and generalizability [18]. The shift in research methodologies increasingly favors approaches that yield broadly relevant, statistically validated results, aligning with the scientific community's emphasis on empirical rigor and generalizability.

However, some scholars question this prevailing focus on statistical significance, warning that it could lead to misconstrued interpretations and might not comprehensively represent the scientific value of a study. This conversation highlights the complex nature of ascertaining research's value and impact [21]. Moreover, an excessive concentration on quantitative analysis risks marginalizing the intricate insights that qualitative research, including case studies, can offer. These studies, essential to a diverse research ecosystem, significantly enhance our understanding of medical conditions and treatments with their detailed narrative accounts.

Journals may consider implementing a comprehensive publication strategy that acknowledges the importance of both qualitative and quantitative research. This could involve setting editorial policies that ensure a diverse mix of article types, including case reports. Journals could also foster interdisciplinary collaborations where case reports are integrated with larger studies, highlighting their complementary nature. Promoting a culture that values diverse methodologies and perspectives in research can enrich the academic discourse and lead to a more comprehensive understanding of medical science.

Financial Considerations
Not all journals rely on author publication fees for their operations. Some benefit from alternative funding methods, such as institutional subsidies or subscription-based revenue [22]. However, the majority typically operate on the author fee model, posing a significant financial consideration. This situation is particularly challenging for case reports, which may not attract as much funding or sponsorship as larger research studies due to their unique and highly specialized nature. As a result, they might not appeal to a broad readership, leading to lower citation rates and, subsequently, lesser financial returns for the journal.

Despite these challenges, it is crucial not to overlook case reports solely because of financial considerations. These reports make a unique contribution to the field of medical knowledge and practice. Journals are advised to explore innovative funding models that support the sustainable publication of case reports. Such models would enable the continuous inclusion of these invaluable reports in scientific literature, ensuring that essential medical insights and discoveries are not neglected due to financial constraints.

In exploring alternative funding models for case report publication, journals may consider the implementation of a tiered fee structure. This approach would involve varying charges based on several factors, including the type of article, the economic conditions of the authors' home countries, and the financial situations of the authors themselves. This nuanced strategy acknowledges the diverse economic circumstances that researchers face globally and aims to strike a balance between equity and financial sustainability. Additionally, there is potential value in seeking sponsorships and grants specifically earmarked for case report publication. Collaborations with medical institutions or societies that prioritize the dissemination of case reports could also serve as valuable funding sources. Furthermore, forging partnerships with educational institutions where case reports are employed as educational tools could provide financial support while simultaneously enhancing the educational impact of these publications.

Implementing a tiered fee structure for case report publication does indeed raise concerns regarding equity, potentially favoring researchers from more economically advantaged regions. However, when executed thoughtfully, this model has the potential to enhance inclusivity and accessibility across a broad range of economic backgrounds. A pivotal element of this approach involves adjusting fees in alignment with the World Bank's economic classifications, thereby making publication more affordable for researchers from lower-income countries. In addition, the establishment of a robust waiver and discount policy is essential to ensure that researchers with limited financial resources can still disseminate their work. This necessitates the implementation of a transparent and equitable application process for fee reductions. Furthermore, fostering partnerships with academic and non-profit organizations can help create a subsidy pool, which can be instrumental in supporting researchers facing financial constraints. These strategies not only serve to mitigate inequities but also contribute to the development of a more inclusive scholarly environment. Consequently, while valid concerns about equity exist, the careful implementation of a tiered fee model can successfully strike a balance between open access and financial realities, ultimately benefiting the global research community.

Key Insights for Mastering Case Reports

The creation of a case report in medical literature necessitates thoughtful consideration and a structured presentation. This process commences with the selection of a pertinent topic, a task requiring constant vigilance from medical students and professionals. These individuals must be vigilant in identifying rare or interesting cases, though locating a reportable case that justifies in-depth research presents a challenge. Key attributes of a well-written case report include coherence, succinctness, and the ability to engage the reader. Typically, these reports explore a range of topics, such as rare discoveries, adverse reactions to treatments, misdiagnoses due to symptom overlap with other diseases, new theoretical insights, challenges to established theories or practices, and significant treatment impacts made by the author.

The effectiveness and clarity of a case report hinge on its structured format. The construction of a case report begins with an abstract, providing a summary, typically under 150 words. This segment introduces the case, delineates treatments, and summarizes medical findings. Subsequently, the introduction offers a literature review connecting the case to existing medical theories and accentuating pertinent issues and challenges, culminating in a succinct description of the patient's condition. The case report section, forming the document's core, details the patient's medical history, examination results, treatments, expected and actual outcomes, emphasizing focused and relevant information. The discussion, a crucial part of the report, builds upon the introduction, elucidating the case's significance, the issues it resolves, and its relevance to the broader medical field. This section also evaluates whether the case supports or refutes current medical theories and its implications for future clinical practice. The conclusion articulates the author's evaluations and findings, highlighting the report's key points and possibly offering recommendations for clinical practice, educators, and researchers. Some journals may amalgamate the discussion and conclusion into one cohesive section.

Ethical considerations, including obtaining consent and safeguarding patient anonymity, play a pivotal role throughout this process. Authors should commence report writing only after securing signed consent forms from patients or their guardians, as applicable. Navigating the intricate landscape of ethical considerations and consent challenges in medical literature requires a deep understanding of various legal frameworks, such as the General Data Protection Regulation (GDPR) in the European Union and the Health Insurance Portability and Accountability Act (HIPAA) in the United States, as well as other region-specific regulations. To effectively manage this complex legal environment, medical literature should establish clear ethical guidelines and consent protocols that align with the legal requirements of the relevant jurisdiction. This approach enables journals to strike a responsible balance between adhering to ethical and legal mandates while disseminating crucial clinical information that advances patient care and medical research.

It is imperative to acknowledge the variability in formatting standards among different journals. Therefore, authors must familiarize themselves with the precise formatting instructions specified by their intended publication. With these essential elements duly addressed, a well-structured case report holds the potential to make substantial contributions to the realm of medicine by offering valuable insights and serving as a compass for future research and clinical practice.

Conclusion

When evaluating case report submissions for journal publication, it is essential to strike a judicious balance between recognizing their importance in enhancing medical knowledge and addressing the inherent limitations of the publishing process. The application of innovative and adaptable editorial methods is crucial in achieving this balance. These strategies enable the smooth integration of case reports into journals, effectively overcoming both practical and editorial challenges.

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