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Case reporting has gotten a bad name, largely because of ‘evidence-based-medicine’ (EBM). EBM puts case reports and technical notes right at the bottom of the EBM ladder: eminence-based (level V) versus evidence-based (level I) medicine. Level V evidence represents a sort of scientific low life. This is rather strange, as we shall see, but let’s follow the argument.1
As the name suggests, EBM is about finding evidence and using that evidence to make clinical decisions. EBM seeks to make our diagnoses less ‘subjective’. A cornerstone of EBM is the hierarchical system of classifying evidence. This hierarchy is known as the levels of evidence. Physicians are encouraged to find the highest level of evidence to answer clinical questions. Orthopaedic journals prefer to publish level I studies and systematic reviews in order to attract readers and to stimulate citations. As a consequence, with the introduction of the EBM movement, orthopaedic journals now publish fewer case reports. Many journals now refuse them, because case reports are not often cited and are supposed to have a negative influence on impact factor.
The argument is that EBM is an important instrument for guaranteeing quality in medical care: that this is how we all should work.
But do we really implement this for all our patients? I dare say that in daily practice we don’t. For clinicians, it may seem that EBM is trying to devalue clinical judgement, intuition, practical experience and wisdom, which better fits into what we call real-world evidence.2
The art of medicine
There is something that we call ‘the art of medicine’. Before explaining in detail what I mean, let’s take an example away from our field. Imagine that your family has an old bronze, which you have had forever, or so it seems. Your grandfather found it in Egypt, ages ago. He always …
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