‘I am very pleased to tell you that your coronary arteries are normal’ – these were the only words that Joan remembered the cardiologist telling her after her angiogram. Perhaps the amnesic effect of midazolam had an influence of this; or perhaps not. As reassuring as this sounded, it did not feel like the conclusion to the problem that she was hoping to achieve. Today was the culmination of a journey which had started with an ambulance trip to A&E, 6 weeks earlier, following a ‘111’ call; after two normal ECGs a 12 hour stay on the clinical decision unit and a negative troponin she was back with her GP describing her episodic central chest pain – sometimes exertional, sometimes not. She was 65 and had a few ischaemic risk factors – certainly enough to justify a referral to the chest pain clinic. A proforma was completed, an exercise test was equivocal, and an angiogram was performed with surprising speed and efficiency. ‘What should I do if I get it again?’ – she asked the nurse who handed her the discharge paperwork. ‘You will have to discuss that with your GP…..’.

Her son, a family acquaintance of mine, read the cardiology discharge summary out to me over the phone: ‘It says she has atypical chest pain’ – incidentally the same diagnosis she had been given in A&E 6 weeks earlier – ‘so what does that actually mean?’. An interesting question indeed.

‘Rule-out medicine’

It’s easy to have a pop at specialists with a case like this, but that is not the intention of this blog. If we are honest, most hospital clinicians have been guilty of making a ‘non-diagnosis’ once or twice. The phenomenon of ‘rule-out medicine’ was even the subject of a symposium at an acute medicine conference that I attended in London a few years ago; erudite speakers described the increasing sensitivity of testing strategies in conditions such as pulmonary embolism (PE), acute coronary syndrome (ACS) and sub-arachnoid haemorrhage (SAH). Never again would patients be sent away from the acute medical unit with even a remote possibility of one of these life-threatening conditions. Our indemnity insurers could breathe easily in their beds at night once more.

Of course, our patients’ breathing may not be quite so relaxed. A symptom severe enough to justify a visit to the hospital, deserves an explanation; but how often does the medical clerking – and even the consultant ward round – conclude with the words ‘Plan: exclude PE’ (or ACS / SAH)? Exclusion of a serious diagnosis may provide the reassurance we need to discharge a patient from hospital; however it is equally important to consider what is causing the symptoms. Chest pain should never be described as ‘non-cardiac’ or (worse still) ‘atypical’.

When we wrote up our first year’s experience of outpatient management for patients with suspected PE, almost 10 years ago, we concluded that a group of patients could be managed without hospital admission. All of the (albeit carefully selected) patients in whom pulmonary embolism was identified over this period had been managed safely in the community, with no readmissions or unexpected deaths; however there was a small group of patients in whom the outcome was less positive. All of these were patients in whom PE was excluded, but where no explanation for the symptoms had been identified. Many returned to hospital soon after discharge, and although only a small number were subsequently found to have a significant condition, the message was clear: a positive diagnosis is important. ‘Not a PE is Not a Diagnosis’ became my mantra.

Of course medicine is not always that simple; it is often much easier to tell a patient what is isn’t, than to tell them what it is. Sometimes there remains a list of possibilities: a differential diagnosis with pointers towards several different causes – to pick one would be disingenuous; furthermore there is no test which will prove that a pain is of musculoskeletal or oesophageal origin with the degree of certainty with which we can exclude a cardiac cause. Communicating uncertainty to a patient without raising anxiety is a skill which all acute physicians, and other hospital specialists need to develop. But, equally important is that we make the effort to think about the cause of a patient’s symptoms; ruling out serious pathology should not be the conclusion of our role.

Providing advice on what to do if a symptom recurs following discharge is another crucial component of hospital care. Chest pain resulting from of oesophageal spasm can be severe, tends to be recurrent and invariably happens at rest. If a patient phones 111, it is very likely that the call will result in an ambulance trip to A&E, particularly if they have cardiac risk factors. A clear explanation of the likely cause of the patient’s symptoms, combined with a management strategy in the event of recurrence may prevent repeated visits to hospital, which tend to raise anxiety and uncertainty yet further. General Practitioners are highly skilled in communicating and managing uncertainty, but the practicality of the advice to ‘discuss that with your GP’ and the likelihood of recurrence while awaiting an appointment needs to be questioned.

Joan was fortunate to have a fantastic General Practitioner – one of the best in the area. He listened to her symptoms, which sometimes related to exertion, but were also exacerbated by certain movements and posture. He also noted that they often occurred when she was tired or stressed and that their onset coincided with the anniversary of her husband’s death. She fought back tears as she described how lonely she felt at times since then. Reassured by her normal coronary arteries, a diagnosis of musculoskeletal chest pain, exacerbated by anxiety and depression, was made; a management plan was instigated, which saved further visits to A&E, or calls to 111. Joan had reached a satisfactory – but sadly atypical – conclusion, to her fairly typical chest pain.

The case report had been written, submitted, rejected and re-written three times; this was getting frustrating for Sarah. When her consultant had suggested she write up this case, it seemed that her prayers had been answered – that gaping hole in the ‘publications’ section of her CV would soon be filled, improving her chances of being short listed for a specialist registrar post in her chosen speciality. However, as she now contemplated yet another re-drafting of the manuscript which stared back at her from the computer screen, she wondered whether revising for her forthcoming PACES examination would be a better use of her time…

Many of us have been in this situation – getting a case report published can certainly be a frustrating business; if there was an ‘I’ve been rejected by the BMJ / NEJM / Lancet’ T-shirt, I would have a small collection by now. But as the editor of a journal I now see this from the other side. The pressure to publish means that the volume of case reports received on a weekly basis far exceed the number we can include, so most will be rejected. Selecting those which are likely to be of greatest value to the readers of the journal is not a particularly scientific process – and I will not claim that we always get this right. But there are things which you can do to make the job of the editor easier, and improve your chances of success.

In this blog, I have summarised a few tips, which I hope may help those who are struggling to get that first elusive publication.

• Focus on the ‘learning points’:

In my view, cases should be more about ‘learning’ than ‘reporting’. Clinicians are busy people – if we are going to invest 15-20 minutes of our time to read a case report we need the outcome to be more than just a ‘raise of the eyebrows’. I like to think that, after reading the report, my practice will change and I will do something different as a result; something that makes me say ‘Wow – I am so glad I read that’, or ‘the next time I see a patient with that problem I will have to look out for that’. So ask yourself what you, and your team learned from the case and summarise this into some learning points around which the case history and discussion can be structured.

• Rarity does not always equate to publishability:

Common things occur commonly, but there are a lot of rare conditions; so it’s actually not unusual to see a patient with something unusual presenting on the acute medical take. A patient with a really rare condition can cause a diagnostic challenge, but the chances of anyone ever seeing it again are slim: there may be learning points around the diagnostic process, but the rarity does not make it publishable in itself. Of course, if your literature search suggests that this is the ‘first ever’ case of something really important then you have an opportunity to pitch this to one of the top international journals – but you should still prepare yourself for an uphill struggle.

• Select your journal / audience carefully

A common reason for rejection of a case report is that the focus is not right for the target audience of the journal. Although the patient may have presented to the acute medical take, if the learning points relate to the subsequent specialist or outpatient care, there may be limited relevance to a journal whose readers are mainly acute physicians. Discuss this carefully with your colleagues and co-authors – getting it right first time will pay dividends.

• Read some back issues before you submit

It’s a good idea to look at the style of previously published case reports in the journal you have chosen; make sure the format of your article is similar. Most journals also have an ‘instructions for authors’ page on their website. Read this carefully and follow to the letter.

• Keep the ‘case history’ focussed

The case history needs to include information relevant to your learning points, but does not need to be a full reproduction of the patient’s clerking or progress notes. In general ‘less is more’ in this situation. Relevant blood tests can be tabulated and remember to include images of x-rays, scans and ECGs where relevant.

• Make the discussion a true ‘discussion’

The ‘discussion’ section should not simply be a literature review, but provides the opportunity to highlight aspects of the patient’s presentation which illustrate the learning points which you summarised at the start. This will usually involve some reference to the relevant literature, highlighting similarities or differences to previously published cases; however exhaustive repetition of material which can easily be found in a recent NICE guideline or Cochrane review is not the best use of this space. Ask yourself how this patient changed your practice and what made it important to share this; what was it that enabled you to reach the diagnosis, or where did you go wrong? What were the key aspects of the patient’s history, examination or investigation which made the difference? If more than one treatment option exists, which did you choose and why?

• Don’t forget to talk to the patient and ask for their consent

Case reports are essentially patient stories – the information belongs to the patient and therefore should not be published without their consent. Some journals do not insist on written consent, except for the publication of images; however it is still good practice to obtain this before submission. You can usually download a consent form from the journal’s website. Although the case history should always be anonymised, the authors’ details will usually indicate the hospital at which the patient was treated, and it will often be possible for patients to be identified from the clinical information, particularly if the problem is unique or unusual. The increasing accessibility of journals via the internet, along with the ability for readers to ‘screen grab’ and share via social media raises the likelihood of a patient or acquaintance recognising their story. In some cases consent can be difficult to obtain – for example if the patient has died, or cannot be contacted; some editors may still be prepared to publish, but it is worth sending a covering email detailing the efforts you have made to obtain this, and the reasons why you believe the case should still be published.

• And finally: proof read carefully – and don’t rely on your spell checker

As an Editor, nothing is more frustrating than a badly written paper, filled with spelling or grammatical errors which obscure an otherwise interesting case. Spell checkers work – up to a point – but won’t correct most medical terminology and plenty of words have alternative spellings which won’t be identifed as incorrect. All ‘track changes’ should be removed, and make sure all the authors are happy with the final version. It is also worth getting a senior colleague with publication experience to read and critique the paper before submission.

Rejection can be frustrating, and redrafting can be time consuming; hopefully, following these tips will improve the chances of turning your ‘good case’ into a great case report.