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How to write a medical...

How to write a medical case report

Related content
Peer review
Seema Biswas , editor-in-chief, BMJ Case Reports, London, UK ,
Oliver Jones , student editor, BMJ Case Reports, London, UK

Two BMJ Case Reports journal editors take you through the process

This article contains...

- Choosing the right patient

- Choosing the right message

- Before you begin - patient consent

- How to write your case report

- How to get published

During medical school, students often come across patients with a unique presentation, an unfamiliar response to treatment, or even an obscure disease. Writing a case report is an excellent way of documenting these findings for the wider medical community—sharing new knowledge that will lead to better and safer patient care.

For many medical students and junior doctors, a case report may be their first attempt at medical writing. A published case report will look impressive on your curriculum vitae, particularly if it is on a topic of your chosen specialty. Publication will be an advantage when applying for foundation year posts and specialty training, and many job applications have points allocated exclusively for publications in peer reviewed journals, including case reports.

The writing of a case report rests on skills that medical students acquire in their medical training, which they use throughout their postgraduate careers: these include history taking, interpretation of clinical signs and symptoms, interpretation of laboratory and imaging results, researching disease aetiology, reviewing medical evidence, and writing in a manner that clearly and effectively communicates with the reader.

If you are considering writing a case report, try to find a senior doctor who can be a supervising coauthor and help you decide whether you have a message worth writing about, that you have chosen the correct journal to submit to (considering the format that the journal requires), that the process is transparent and ethical at all times, and that your patient is not compromised in your writing. Indeed, try to include your patient in the process from the outset, and always gain consent.

A case report is the first line of medical evidence, and over time has become an important medium for sharing new findings (box 1). High quality case reports successfully bring together the various domains of medicine such as physiology, pathology, and anatomy. Using the patient as the focus, case reports provide a clinical “coat peg” on which to hang this knowledge.

Box 1: Notable case reports through the ages

Many case reports have changed the way clinicians view health and disease. For example, in 1861 the French surgeon Pierre Paul Broca reported the case of a dysphasic patient nicknamed “Tan”—owing to his inability to say any other words. After Tan’s death, Broca did an autopsy and discovered a syphilitic lesion in the frontal lobe of the brain, leading to the hypothesis of a speech centre in the brain—later known as Broca’s area. 1 Other notable case reports have documented the discovery of the Bence-Jones protein, 2 the first descriptions of Parkinson’s disease, 3 and AIDS. 4

Choosing the right patient

We can learn from all patients, but choose a patient from whom there is something new to learn. Search the literature and decide whether the topic you want to discuss, whether clinical or non-clinical (a radiological or microbiological finding, for example), has already been well discussed.

Your patient should ideally be someone who is not simply a willing participant in this process but someone who wants their story to be told to educate students, doctors, and other patients. Many journals have an option for patients to contribute to the manuscript.

Choosing the right message

Rare diseases are not in themselves a reason to write up a case, but unusual presentations of a common disease are important to communicate to the medical community. Early or subtle signs and symptoms that are easily missed are important for us to learn from. Indeed, the learning value of your case is the single most important factor in determining whether it is likely to be published.

Have in mind the journal that you want to submit your manuscript to before you begin to write. Your case and the message should fit with the style of the journal, whether a specialist journal, a case reports journal, or a journal that publishes case presentations in different formats. This may include question and answer formats, quizzes, or even interactive online educational formats useful for exam revision—for example, Endgames ( The BMJ ), Epilogue ( Archives of Disease in Childhood ), or Images ( New England Journal of Medicine ). These adapted formats are important, as most of these journals no longer accept case reports written in their traditional format.

Also, be careful in your claims about new diseases and new treatments. Case reports cannot make claims about the efficacy of novel treatments on the basis of individual cases and limited follow-up time. The most important message is a new or novel learning point—that is, the educational message.

Before you begin

Once you have chosen your patient and discussed with them what you would like to write, show them the case report so that they may give informed consent to your manuscript submission and familiarise themselves with the website.

It is important that a patient understands how their case will appear online or in print and that they truly give informed consent. You should do this under the supervision of the senior doctor who is the supervising coauthor of your manuscript; ideally, the senior doctor would obtain consent.

Writing the case report

Case presentation.

Begin with the case presentation (box 2): describe your encounter with the patient, their symptoms, and their signs. You should already have an idea what your take home messages will be. If the journal presentation of the case report allows, you can write these take home messages as bullet points (box 3).

Box 2: Case presentation

Acute pancreatitis and severe hypertriglyceridaemia masking unsuspected underlying diabetic ketoacidosis.

After 48 hours of anorexia, nausea, and non-bloody vomiting at home, the patient presented to her local hospital, where the diagnosis of moderate acute pancreatitis was made, based on an abdominal computed tomogram and ultrasound and serum chemistry. Ongoing symptoms, including left upper quadrant, 7/10 stabbing pain with generalised abdominal cramps, led to her transfer to the closest tertiary hospital for further management.

On admission to the tertiary hospital, the patient was treated as having uncomplicated pancreatitis. Immediate management included intravenous rehydration therapy, antiemetics, and narcotics for pain control with further orders for nothing to be ingested until the patient was re-evaluated. Initial assessment of the patient showed a temperature of 37.3ºC, heart rate 110 beats/min, blood pressure 126/68 mm Hg, respiratory rate 14 breaths/min, and oxygen saturation 98% on room air. She had a normal body habitus and was not in distress; however, she had a moderate amount of abdominal discomfort. Her physical examination showed no xanthalasmas or skin eruptions, nor was a fruity odour detected. Her gastrointestinal examination showed diffuse tenderness, with a soft, non-distended abdomen. Also, no organomegally was noted. Other than tachycardia, her cardiorespiratory examination was unremarkable with the notable absence of tachypnoea.

The patient was previously healthy without any medical history or surgical history. Her medication list was limited to the oral contraceptive pill (ethinyl oestradiol, norgestimate). The patient described only occasional social alcohol consumption (none within the last week) and no binge drinking or recreational drug use in the past. There were no recent surgeries, gastrointestinal endoscopic procedures, or abdominal trauma. She denied fever, chills, rigors, or recent unintended weight loss. There was no history of polyuria or polydipsia.

She did not have any prodromal abdominal symptoms There had been no similar episodes previously. There was no family history of dyslipidaemias, pancreatitis, or gallstones. Her family history was relevant for rectal carcinoma in her paternal grandfather and type 2 diabetes in her maternal grandmother. Six hours after her arrival at the tertiary hospital, and 12 hours from her first presentation and assessment at the local rural hospital, the patient began to decompensate with rapid progression of hypotension, tachycardia, and tachypnoea. The acute decompensation to hypotension and shock was assumed to be due to progression of the pancreatitis with potential infection complicating the pancreatitis. The patient was aggressively rehydrated and started on broad spectrum antibiotics. However, the hypotension failed to respond to fluid resuscitation and there was increased patient distress. She was urgently referred to the intensive care unit for supportive measures and management.

Aboulhosn K, Arnason T. Acute pancreatitis and severe hypertriglyceridaemia masking unsuspected underlying diabetic ketoacidosis. BMJ Case Rep 2013;2013, doi: 10.1136/bcr-2013-200431 .

Box 3: Learning points

Postpartum hellp syndrome and subcapsular liver haematoma.

Subcapsular liver haematoma is a potentially life threatening complication of severe pre-eclampsia and haemolysis, the breakdown of red blood cells; elevated liver enzymes; low platelet count syndrome.

The complication is rare but should be considered with severe upper abdominal pain in obstetric patients, especially in the presence of pre-eclampsia.

Real time ultrasound imaging of the liver is often diagnostic.

Messerschmidt L, Andersen LL, Sorensen MB. Postpartum HELLP syndrome and subcapsular liver haematoma. BMJ Case Rep 2014, doi: 10.1136/bcr-2013-202503 .

You should separate your case presentation section from the investigations and differential diagnoses. The key points to remember to include are your choice of investigations and how they helped you establish a working diagnosis (box 4).

Box 4: Investigations

Unilateral presentation of postpartum cardiomyopathy misdiagnosed as pneumonia.

On arriving at the emergency department, the patient had severe shortness of breath at rest 10 days after delivery. Her vital signs included an oral temperature of 36.7ºC, blood pressure 163/102 mmHg, pulse rate 146 beats/min, and oxygen saturation 88% in room air. Treatment with supplemental oxygen by mask yielded an increase in oxygen saturation to 95%. Her physical examination revealed no jugular venous distension, hepatic enlargement, or pedal oedema; heart sounds were fast and regular, with no evidence of murmurs or additional sounds. On lung auscultation bilateral crackles were present. Her laboratory analysis showed mild non-specific indicators of stress with a leucocyte count of 9.3×10 3 cells/mm 3 , haemoglobin value of 10.6 g/dL, and a platelet count of 791×10 3 cells/mm 3 . Her electrocardiogram was similar to the one obtained a day earlier showing T wave inversion in leads V4–V6; however, chest radiography showed a more bilateral presentation compared with the previous one showing both heart enlargement and pulmonary oedema. A chest computed tomography angiography performed to exclude pulmonary artery embolisation confirmed the presence of cardiomegaly and pulmonary oedema with bilateral effusions (fig 1). ⇓ An echocardiogram showed a diminished ejection fraction of 15-20% confirming the diagnosis of postpartum cardiomyopathy.

Amit BH, Marmor A, Hussein A. Unilateral presentation of postpartum cardiomyopathy misdiagnosed as pneumonia. BMJ Case Rep 2010, doi: 10.1136/bcr.05.2010.3039 .

Fig 1 Chest computed tomogram performed after deterioration showing heart enlargement, pulmonary oedema, and bilateral pleural effusions mainly on the right. From Amit BH et al. BMJ Case Rep 2010, doi: 10.1136/bcr.05.2010.3039 .

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Imagine that you are presenting at a grand round and have to explain your choices to your colleagues—this is essentially what you are doing as you write your case report. Do not simply list your differential diagnoses; describe how you worked through your list of differentials and how you established a final diagnosis.

Also, make sure you collect and include high quality and well annotated images that not only explain radiological findings but also show their importance in establishing your diagnosis.

Good quality annotated images

Fig 2 Craniocervical x ray film showing fusion of the posterior arch of C1 to the occiput. A fracture was not evident, but clinical suspicion prompted a computed tomography scan

Fig 3 Axial, left, and sagittal, right, computed tomography scans of the craniocervical junction at presentation showing fusion of the left occipital condyle with the lateral mass of C1 and a fracture involving both elements. The fracture is indicated by the arrowheads

Outcome and follow-up

The outcome and your follow-up of the patient are important. In both your case presentation and the section on patient outcome, you should describe what happened to your patient in terms of their specific symptoms, their general wellbeing, and their lifestyle and activity.

Some journals require you to write a summary of your case report. This usually has a word limit and appears in medical search engines, such as Pubmed/MEDLINE. It is the equivalent of the abstract of a research paper.

Ensure that your title is scientific and clinical. Cryptic and humorous titles translate poorly across a global audience and do not always accurately reflect the content of your case report. You may find that the word limit does not permit you to write all the detail you would want to include in the summary, but the background section allows you to do this. Try to make sure that the background section does not repeat the summary.

Publication process

Clinical videos and images are important alternatives or potential additions to clinical case reports which many journals encourage authors to submit. Again, prepare these in collaboration with clinical teachers or coauthors, who will help you annotate these images and point out important learning messages, and do this from the outset in the format of the journal that you have researched well and decided to submit your manuscript to.

All submitted case reports are usually sent for peer review. Reviewers are chosen according to their specialty and clinical or academic interests. Your choice of key words is therefore important as these are the basis for the assignment of reviewers. Keywords are also important for other authors doing literature searches who discover your case report and cite this in their own writing.

Decisions to accept, revise, or reject are based on editors’ and reviewers’ opinions together, and every attempt is made to ensure that criticism is constructive and useful.

Dependent on how quickly your manuscript is reviewed, you should receive a decision on your manuscript within three to six weeks of submission. Outright rejections for reasons such as the unsuitability of your manuscript for the particular journal and its audience, manuscripts in the wrong format, incomplete sections (especially the case presentation and differential diagnosis sections), and plagiarism tend to be prompt, and they would be easily avoided by following the steps above and choosing your patient, your topic, your journal, and your particular manuscript format well.

Rejections on the basis of the content of the case report tend to be at the peer review stage and may be a few weeks after submission. They could include reasons such as the lack of novelty or educational message, a poor literature search, or inconsistent clinical management. Again, this is avoidable by preparing well. It is unusual for a well thought out and well prepared manuscript to be rejected.

Autoformatting software, especially with references, may produce errors, so do double check these. Syntax errors, spelling mistakes, and poor grammar create a poor impression of an otherwise good case report. As always, first impressions matter, so be meticulous as you proofread your manuscript before you submit.

The entire process of publication depends on the number of revisions necessary and how quickly you submit a revised manuscript. For those of you aiming to submit in time to prepare for job applications, do take into account the time taken in the process of publication.

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Open access
Published: 27 November 2013

A guide to writing case reports for the Journal of Medical Case Reports and BioMed Central Research Notes

Richard A Rison 1

Journal of Medical Case Reports volume 7 , Article number: 239 ( 2013 ) Cite this article

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Case reports are a time-honored, important, integral, and accepted part of the medical literature. Both the Journal of Medical Case Reports and the Case Report section of BioMed Central Research Notes are committed to case report publication, and each have different criteria. Journal of Medical Case Reports was the world’s first international, PubMed-listed medical journal devoted to publishing case reports from all clinical disciplines and was launched in 2007. The Case Report section of BioMed Central Research Notes was created and began publishing case reports in 2012. Between the two of them, thousands of peer-reviewed case reports have now been published with a worldwide audience. Authors now also have Cases Database, a continually updated, freely accessible database of thousands of medical case reports from multiple publishers. This informal editorial outlines the process and mechanics of how and when to write a case report, and provides a brief look into the editorial process behind each of these complementary journals along with the author’s anecdotes in the hope of inspiring all authors (both novice and experienced) to write and continue writing case reports of all specialties. Useful hyperlinks are embedded throughout for easy and quick reference to style guidelines for both journals.

Peer Review reports

Introduction: the importance of case reports

Case reports are a time-honored tradition in the medical profession. From Hippocrates (460 B.C. to 370 B.C.), and even arguably further back since the papyrus records of ancient Egyptian medicine (c. 1600 B.C.) to modern day, physicians of all specialties have described interesting cases involving all specialties [ 1 , 2 ]. Published case reports provide essential information for optimal patient care because they can describe important scientific observations that are missed or undetected in clinical trials, and provide individual clinical insights thus expanding our knowledge base [ 3 ].

The publication of case reports has indeed become a standard lexicon of the medical literature. Examples abound. Few practicing physicians would not know for instance the significance and subsequent discovery of a disease whose first description in 1981 began with the title in the medical case report literature as: “A preliminary communication on extensively disseminated Kaposi’s sarcoma in a young homosexual man” [ 4 ]. There is no neurologist that I know who is unfamiliar with the disease whose description began in 1817 by James Parkinson (1755 to 1824) with the title “An essay on the shaking palsy.” [ 5 ].

Yes, both of the above-mentioned famous diseases (the acquired immunodeficiency syndrome and Parkinson’s disease) were first described in the case study format. The act of recording, discussion with colleagues, and publishing our clinical observations with patients remains essential to the art of medicine and patient care. As Osler once said “Always note and record the unusual…Publish it. Place it on permanent record as a short, concise note. Such communications are always of value.” [ 6 ].

But how and when should we do this? Early case reports were little more than personal communications between colleagues about unique and interesting patients seen in their respective medical practices. This anecdotal reporting has evolved into an accepted form of scholarly publication with the ability to rapidly disseminate knowledge to a broad medical audience [ 7 ] using the generally accepted format of a title, abstract, introduction (background), case presentation, discussion, conclusions, and references. Many biomedical journals publish case reports and provide authors with guidelines that provide instruction for acceptance criteria, content, and format and give advice on relevant patient case reports that merit publication [ 3 ].

There are already many well-written published articles on how and when to write a good case report (please see Recommended further reading section at the end). I will not re-invent the wheel, but within this editorial I hope to provide an informal guide on how and when to write a case report for BioMed Central (BMC), in particular the Journal of Medical Case Reports ( JMCR ) and BioMed Central Research Notes ( BMCRN ). The utility of the newly created Cases Database will also be discussed. Relevant and useful website links will be used throughout to allow the reader easy access to further information on BMC requirements. I also hope to impart to the reader a brief overview of case report editorial flow in both JMCR and BMCRN along with the complementary relationship between both journals. I will also give anecdotes of how I personally approach things.

Definitions

What exactly is a case report? From peer-reviewed journals to Wikipedia (and yes, I read Wikipedia like we all do) definitions are readily available and generally agreed upon. A simple online search shows the following definition from “thefreedictionary.com” [ 8 ]: “Case Report A report of a single case of a disease, usually with an unexpected presentation, which typically describes the findings, clinical course, and prognosis of the case, often accompanied by a review of other cases previously reported in the biomedical literature to put the reported case in context.” Wikipedia [ 9 ] has this to say: “In medicine, a case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports may contain a demographic profile of the patient, but usually describe an unusual or novel occurrence. Some case reports also contain a literature review of other reported cases.” Whether one uses the above definitional references or older more classic ones [ 10 ], all are in agreement.

How to start: the patient

Things start at the bedside or in the office with the most important person involved: the patient. Patients and their stories (including from their friends, coworkers, and family) are our portal to writing the case report. Patients (both in-patients and out-patients) are assessed, we confer with colleagues, appropriate investigations then follow, and treatment if possible begins. If I encounter an in-patient on call then I follow him or her throughout his or her hospitalization and, I hope, timely discharge. The patient is then followed and reexamined in the office over the course of time to see how the clinical course evolves. I usually wait 6 months over the course of multiple visits before I actually begin to write a case report so as to allow enough time for the clinical course to play out. Of course if the patient is hospitalized with an acute and rapid illness then this time may be much shorter, but I still follow him or her with daily neurologic examinations.

Collegial discussion and the Internet: our modern day water cooler

When an interesting condition is encountered in either the hospital or the office setting, I discuss the case in person with both my local neurology colleagues and colleagues of other specialties to see if they have encountered before the clinical scenario that I am dealing with at the time. This is usually a quick face-to-face nursing station conversation. If the case is particularly challenging then I will contact my local university colleagues for their opinion (especially if an urgent transfer needs to be arranged). I then “hit the books”, or at least I used to. Nowadays I usually “hit the keyboards” which are plentiful at every hospital nursing station and in my office. Indeed, the Internet seems to have become our modern day replacement for office water cooler conversations. Since it is readily available (and free to me because I am a member of the staff) in the hospital in which I see patients and in my office, I usually start with UpToDate® [ 11 ] and then click the links to individual references. Further reading is then supplemented by both PubMed [ 12 ] (free) and Cases Database (also free) [ 13 ] (see later). If I feel that a particular patient warrants a case report, then I continue to read more and more. There are also medical list servers and medical online communities to which one can post a case with de-identified images online and petition the advice of colleagues worldwide. I use both Neurolist [ 14 ] (a membership-only service, but membership is free) and The American Academy of Neurology (AAN) for my specialty and/or subspecialties [ 15 ] (also a membership-only service, the fee of which comes out of my yearly AAN dues). Another useful list server is sermo® [ 16 ], which has free membership. Teaching grand rounds at one’s local university or hospital, poster presentations, and simple discussion with professors giving lectures at local seminars are also good (and previously “traditional”) places to start. I have always preferred an in-person encounter to discuss a case with a colleague or professor, but given the current day and age (daily workload, travel costs, time away from the office and family, and so on), I have found Internet-based discussion (keeping all patient information anonymous of course) very helpful.

The BMC series, JMCR , and BMCRN : a brief history

The BMC series is a group of open access, peer-reviewed journals that spans most areas of biological and clinical research. There are currently 65 journals in the series, including (alphabetically) BMC Anesthesiology to BMC Women’s Health. Some of these publish case reports within their respective disciplines, and some do not [ 17 ].

JMCR is an online, open access journal under BMC auspices dedicated mainly to the publication of high quality case reports, and aims to contribute to the expansion of current medical knowledge (please see specific publication criteria below). It was created and founded by Michael Kidd and colleagues in 2007 and at the time was believed to be the world’s first international medical journal devoted to publishing case reports from all clinical disciplines. In the 5 years since its launch, JMCR has published over 2000 case reports. In 2011, case reports were downloaded from the journal’s website over 1,500,000 times [ 18 ].

BMCRN is also an online, open access journal under BMC auspices publishing scientifically sound research across all fields of biology and medicine. The journal provides a home for short publications, case series, and incremental updates to previous work with the intention of reducing the loss suffered by the research community when such results remain unpublished. BMCRN began publishing case reports in 2012 and now has a dedicated section for case reports [ 19 ].

Please read on to see the complementary relationship of case reporting between the two journals, how they relate to other journals in the BMC series, and further information on editorial work flow including specific publication criteria.

Cases Database: an invaluable resource

Since the launch of JMCR in 2007 and the more recent introduction of case reports to the BMCRN , which aims to have a broader scope, BMC has acknowledged and continues to acknowledge the value of case reports to the scientific literature. To further strengthen this commitment, BMC in conjunction with Michael Kidd have developed the invaluable new resource of Cases Database, a continually updated, freely accessible database of thousands of medical case reports from multiple other publishers, including Springer, British Medical Journal, and PubMed Central. By aggregating case reports and facilitating comparison, Cases Database provides a simple resource to clinicians, researchers, regulators and patients to explore content and identify emerging trends [ 20 ].

http://www.casesdatabase.com/

I find Cases Database indispensable when I research a particular patient’s condition. It is very helpful in seeing if a particular condition has been reported before and what treatment the authors have performed. It is an invaluable resource which can be used to check and see if previous cases have been reported before and how other authors have managed their patients with similar clinical conditions. When I last checked, Cases Database had in its repository 27,915 peer-reviewed medical case reports from 250 journals (!) [ 13 ]. Cases Database is quickly becoming my first go to when reading about a patient’s condition and symptoms.

When to write a case report

How does one determine when to write an actual case report? What constitutes and what are the criteria for publication? Different journals have different criteria, but here are the criteria for JMCR and BMCRN .

JMCR [ 21 ] publishes original and interesting case reports that contribute significantly to medical knowledge. Manuscripts must meet one of the following criteria: unreported or unusual side effects or adverse interactions involving medications; unexpected or unusual presentations of a disease; new associations or variations in disease processes; presentations, diagnoses and/or management of new and emerging diseases; an unexpected association between diseases or symptoms; an unexpected event in the course of observing or treating a patient; findings that shed new light on the possible pathogenesis of a disease or an adverse effect.

http://www.jmedicalcasereports.com/authors/instructions/casereport

BMCRN [ 22 ] has somewhat different publication criteria: BMCRN considers medical case reports that describe any clinical case. Case reports submitted to BMCRN do not need to be novel, but must be authentic cases and have some educational value along with representing at least an incremental advance in the field. BMCRN will not consider case reports describing preventive or therapeutic interventions because these generally require stronger evidence.

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport

Neither BMCRN nor JMCR will consider case reports where there are ethical concerns.

JMCR and BMCRN have the following definitions that authors should know: a single case report, two case reports, or a case series (greater than two reported cases). Both journals follow this format and accept submissions with these title structures.

I tend to classify case reports in my mind generally as follows: diagnosis-related, management-related, or both [ 10 ]. Either type should have clear and concise take-home messages and teaching points. I personally keep a stack of charts labeled “Curious Cases” on a bookshelf within my small office next to my desk which is always within my field of view at work, adhering to the “out of sight, out of mind” principle. Over the years that space has grown and, admittedly, I have cases dating back over the entire span of my years in practice (now over 13 years) which I simply have not gotten around to yet (!).

BMC editorial workflow for case reports: a brief glimpse

If a BMC Series journal editorial team considers a submitted case report unsuitable for their respective specialty journal (and now a growing list of Springer journals that BMC is now affiliated with), the authors are given the option to transfer their manuscript to BMCRN . If this option is exercised, then the BMC editorial team (usually the Case Report Section Editor for BMCRN in conjunction with the appropriate Associate Editor) determines if the manuscript is suitable for BMCRN or if it is more suitable for JMCR (based on the criteria listed above). The manuscripts will then be forwarded on to the respective Deputy and/or Associate Editors for peer review depending on which of the journals the author(s) agree(s) to. Peer reviewers are solicited (usually at least one at BMCRN and at least two at JMCR ). The peer review comments (which are open and identifiable at JMCR and blinded at BMCRN ) are then usually sent to the authors for appropriate revisions and rebuttals (unless it is felt that the manuscript should be rejected outright, at which time the editorial office sends the authors an explanatory letter). After these revisions and rebuttals have been performed, the revised manuscript and rebuttals are sent back to the respective editors for a final decision and recommendations. These decisions and recommendations are then forwarded on to the Editor-in-Chief for final approval for publication. At JMCR , manuscripts are professionally copyedited before being sent off to the production team for publication, whereas at BMCRN the authors are requested to obtain their own professional copyediting (if needed) before publication (the respective costs being reflected within the different article processing charges for both journals). When the manuscripts are published in both journals, they are in the preliminary form before being converted to the final form after production.

Author satisfaction consistently ranks high for the overall process in both journals.

The actual case report

Now let us discuss the brass tacks of writing the actual case report by going through the individual sections that will comprise the manuscript. I will present them in a sequence that matches the journals’ website requirements and provide easily accessible hyperlinks to both respective journals.

The first page of the manuscript should be a dedicated title page, including the title of the article. The title should be a clear and short description of the case with a list of the full names, institutional addresses and email addresses for all authors. There should always be at least one corresponding author who is clearly identified. Abbreviations within the title should always be avoided.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-title

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#title

I usually end the title with “…: a case report” or “…: two case reports” or “…: a case series”. I also try to avoid any puns or overly cute wording within the title and try to keep things strictly descriptive and clear. The title needs to accurately describe the case – after all, this may be all that someone reads. If a cute or clever title is used that obscures what the case is really about, then it may be even less likely that the manuscript is read.

The Abstract should be “short and sweet”. It should not exceed 350 words. Abbreviations or references within the Abstract should not be used. The Abstract should be structured into three sections: Background, an introduction about why this case is important and needs to be reported. Please include information on whether this is the first report of this kind in the literature; Case presentation, brief details of what the patient(s) presented with, including the patient’s age, sex and ethnic background; Conclusions, a brief conclusion of what the reader should learn from the case report and what the clinical impact will be. Is it an original case report of interest to a particular clinical specialty of medicine or will it have a broader clinical impact across medicine? Are any teaching points identified?

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-abstract

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#abstract

I find this is the most important part because this is often all that people will read and its availability will allow easy retrieval from electronic databases and help researchers decide their level of interest in the case report. The Abstract should be a concise and condensed version of the case report and should include the same main sections of the main text and be as succinct as possible [ 3 ]. This is the last thing that I usually write as it tends to flow easily after I have invested my time in thought and writing of the manuscript.

This section is comprised of three to ten keywords representing the main content of the article. It is important for indexing the manuscript and easy online retrieval.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-keywords

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#formatting-keywords

Introduction (Background)

The Introduction ( JMCR ) or Background ( BMCRN ) section should explain the background of the case, including the disorder, usual presentation and progression, and an explanation of the presentation if it is a new disease. If it is a case discussing an adverse drug interaction the Introduction should give details of the drug’s common use and any previously reported side effects. It should also include a brief literature review. This should give an introduction to the case report from the standpoint of those without specialist knowledge in the area, clearly explaining the background of the topic. It should end with a very brief statement of what is being reported in the article.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-intro

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#background

The Introduction or Background serves as the sales pitch for the rest of the manuscript. It should be concise and salient [ 3 ] and immediately attract the reader’s attention to entice him or her to read on.

Case presentation

This should present all relevant details concerning the case. The Case presentation section should contain a description of the patient’s relevant demographic information (without adding any details that could lead to the identification of the patient); any relevant medical history of the patient; the patient's symptoms and signs; any tests that were carried out and a description of any treatment or intervention. If it is a case series, then details must be included for all patients. This section may be broken into subsections with appropriate subheadings.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-case

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#presentation

This is one of the most integral sections. The case should be described in a concise and chronological order. One should usually begin with the primary complaint, salient history (including significant family, occupational, and other social history along with any significant medications taken or allergies), followed by the physical examination, starting with the vital signs presented at the examination, along with pertinent investigations and results. There should be enough detail (but not too much) for the reader to establish his or her own conclusions about the validity. It should contain only pertinent information and nothing superfluous or confusing [ 3 ].

This is an optional section in JMCR for additional comments that provide additional relevant information not included in the case presentation, and that put the case in context or that explain specific treatment decisions.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-discussion

This section should evaluate the patient case for accuracy, validity, and uniqueness and compare and contrast the case report with the published literature. The authors should briefly summarize the published literature with contemporary references [ 3 ].

Although this section is optional in JMCR (and not even listed separately on the BMCRN guidelines website), I find that most authors write this section, or an expanded conclusions section incorporating the elements listed above.

I personally write a separate discussion section and conclusions section for each case report that I author.

Conclusions

This should state clearly the main conclusions of the case report and give a clear explanation of their importance and relevance. Is it an original case report of interest to a particular clinical specialty of medicine or will it have a broader clinical impact across medicine? Information should be included on how it will significantly advance our knowledge of a particular disease etiology or drug mechanism (if appropriate).

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-conclusion

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#conclusions

This should be short and concise with clear take-home messages and teaching points [ 3 ].

Patient’s perspective

This section is an opportunity for patients to add a description of a case from their own perspective. The patients should be encouraged to state what originally made them seek medical advice, give a description of their symptoms, whether the symptoms were better or worse at different times, how tests and treatments affected them, and how the problem is now. This section can be written as deemed appropriate by the patients, but should not include identifying information that is irrelevant to the case reported. As medicine becomes more person-centered, the voice of the individual patient becomes even more important, both to assist in clinical decision making, and for medical education.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-patients

This optional section is unique to JMCR , and I believe adds an important new dimension to the traditional case report. Most authors still do not yet take advantage of this, but I hope as time goes on and more and more open access case report manuscripts are published that this section will be routinely used, not just in JMCR but also in BMCRN and all other BMC clinical journals. I recall one manuscript in particular where the patient himself was requesting publication as soon as possible because of his terminal disease. He wanted his message out there and be available to all to read before he died.

List of abbreviations

When abbreviations are used in the text they should be defined in the text at first use, and a list of abbreviations can be provided, which should precede the Competing interests and Authors’ contributions sections.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-abbreviations

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#formatting-abbreviations

Both JMCR and BMCRN publish case reports over a wide range of medical and surgical specialties, and it is important for the reader who may not be within that particular specialty to readily access a quick list of commontechnical abbreviations. Also, given the open access nature of both journals, please keep in mind that nonmedical professionals may read the manuscript as well.

This section is compulsory for BMC. It should provide a statement to confirm that the patient has given their informed consent for the case report to be published. The written consent should not routinely be sent in along with the manuscript submission (because of patient privacy issues), but the BMC editorial office may request copies of the consent documentation at any time. The following wording is recommended: “Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.” If the individual described in the case report is a minor, or unable to provide consent, then consent must be sought from his or her parents or legal guardians. In these cases, the statement in the ‘Consent’ section of the manuscript should be amended accordingly. Please keep in mind that manuscripts will not be peer reviewed if a statement of patient consent is not present.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-consent

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#consent

In practice, I always start with written consent from the patient. If the patient is incapacitated or deceased, then I obtain consent from the patient’s next-of-kin. Once this is obtained then I place it in the patient’s chart for safe keeping. I find that most patients and family members are quite agreeable to publication as long as their details are anonymous. BMC has very clear and explicit consent criteria and consent forms in multiple languages. I always keep a consent form within my office (and carry a few in my doctor’s handbag for hospital consults) for ready access. After I have obtained consent, I place it in the patient’s chart and keep it my office.

If the patient has died, then I try to obtain consent from the patient’s next-of-kin. This is usually done via telephone or postal mail. If the deceased patient’s family is amenable (and usually they are), then I send them (I never use email when it comes to patient-identifying information) the pre-filled out consent form in their language with a return envelope and paid for postage via the postal service. If I am unable to obtain consent this way in a case involving a patient who has died, then I write in the Consent section the following: “Written informed consent could not be obtained from the deceased patient’s next-of-kin for publication of this case report and accompanying images despite all reasonable attempts. Every effort has been made to protect the patient’s identity and there is no reason to believe that our patient would have objected to publication.”

If the patient was last known to be living but untraceable (or mentally incapacitated without next-of-kin consent), then I just simply do not publish the case.

For further information, please see JMCR and BMCRN website consent section hyperlinks as listed above.

Authors’ information

This section includes any relevant information about the author(s) that may aid the reader’s interpretation of the article and understanding of the standpoint of the author(s). This may include details about the authors’ qualifications, current positions they hold at institutions or societies, or any other relevant background information. Please refer to authors using their initials. Note this section should not be used to describe any competing interests.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-information

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#formatting-information

In practice, I have frankly also personally used this section to advertise my services and “tout” my certifications and subspecialties (along with any co-authors and affiliated institutions) to my surrounding local community. This has in turn given me a modest increase in business (which has been completely non-monetary to date), usually in the form of email-based queries, many of which come from patients outside of my locality.

Acknowledgements

Authors should acknowledge anyone who contributed towards the article by making substantial contributions to conception, design, acquisition of data, or analysis and interpretation of data, or who was involved in drafting the manuscript or revising it critically for important intellectual content, but who does not meet the criteria for authorship. Also included should be the source(s) of funding for each author, and for the manuscript preparation. Authors must describe the role of the funding body, if any, in the: design, collection, analysis, and interpretation of data; writing of the manuscript; and decision to submit the manuscript for publication. Please also acknowledge anyone who contributed materials essential for the study. If a language editor has made significant revision of the manuscript, I recommend that you acknowledge the editor by name, where possible. Authors may also like to acknowledge (anonymously) the patient on whom the case report is based. If a scientific (medical) writer is used, this person should be included in the Acknowledgements section, including their source(s) of funding. Authors should obtain permission to acknowledge from all those mentioned in the Acknowledgements section.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-acknowledgements

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#formatting-acknowledgements

I have had colleagues who do not want to participate in the actual writing of the manuscript or do any actual “work” who have instead preferred to be mentioned in this section only.

Authors must search for and cite published case reports that are relevant to the case they are presenting. There should be no more than 15 references usually, although BMC does publish manuscripts with more references particularly if there is an extended literature review. Unless it is of historic interest, please keep the references as contemporary as feasible (for example, within the last 5 years or so). Please avoid excessive referencing.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-references

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#formatting-references

Cover letter

This is a separate document that should be written and uploaded with the main manuscript submission. I usually write this after I have written the Abstract. The cover letter should be addressed to the Editor-in-Chief in a formal manner and include all of the authors’ contact information. It should clearly and concisely state the title of the manuscript, and why the authors feel that their case report should be published based on any already available literature on the topic at hand. From an editor’s viewpoint, the cover letter is exceptionally important as that is the first thing that he or she reads and serves as the gateway to the Abstract and then the rest of the manuscript.

BMC author academy: help for all

Both JMCR and BMCRN have a large number of non-native English-speaking authors. Since JMCR and BMCRN are both BMC publications whose editorial offices are based in England, the language of publication is of course English. The BMC author academy is a joint program by BMC and Edanz [ 23 ] aimed at equipping writers for successful publication. Their materials have been developed from training workshops that Edanz gives to researchers worldwide and are not just limited to case reports. BMC recommends Edanz for authors who want to have their manuscript edited by a native speaker of English who is a scientific expert. Edanz provides scientific editing and related services that raise the quality of manuscripts to the standard needed to be understood at peer review.

http://www.biomedcentral.com/authors/authoracademy

I find that most non-native English-speaking authors have their manuscripts reviewed informally by a native English-speaking colleague and/or friend who is usually mentioned within the Acknowledgements section. This is understandable to keep costs down. However, please be aware that poor grammar and frequent spelling mistakes can be an impediment to editorial work flow and peer review. The editorial staff for both JMCR and BMCRN are acutely aware and sensitive to this given the large number of international submissions. At both JMCR and BMCRN , submitted manuscripts with questionable grammar and spelling are returned back to the authors by the editorial staff if it is felt that the grammar and spelling mistakes would impede peer review. If these issues are minor and it is felt that they would not impede peer review, then the manuscripts are sent off to peer reviewers (when appropriate).

Final checklist and the rule of C s

After I have completed a case report, I like to run through my long-winded (but useful) “rule of Cs” which is as follows.

Is it C lear, C oncise, and C oherent? Does it C onvey your message? Have you used C ases Database to look for any previously similar reported cases, and included them, if appropriate, in your references? Have you C onferred with your C olleagues on the C ontent? Will it C ause the reader to be C urious? Did you obtain C onsent? Does it C ontain all of the necessary information? Does it C omply with BM C guidelines? Do you think that it may need C opyediting? Do your C o-authors C oncur with the C ompleted paper? C an you C ut anything unnecessary out? Are your findings likely to be a C oincidence or by C hance alone? If so, then mention this in the Discussion section. Is the writing style C onsistent? Many times I find co-authored manuscripts have different writing styles within the same paper depending on who wrote what section. There should be a C entral, C orresponding author who is in C harge and oversees all of this. Is the C ase report written in a C hronological fashion with respect to the patient’s history and C hain of events? Is there anything that can be C ut out and have it still C ontain the C ompulsory information? Is it C oncise? Have you C onveyed C uriosity for your C ase report within your C over letter to the editorial team? Remember: your C over letter is the sales pitch to the editorial team! Make it C ount! Have you used within the manuscript C opyrighted information from another source? If so, do you need and/or have permission for use? After C ompletion, wait a C ouple of days before final submission to C lear your mind and read the manuscript again to C atch any mistakes that you may have made while you were C aught up in the C ompletion of it. Are the references C ontemporary? C an it be C omprehended by the average (“ C ”) reader? Remember, both JMCR and BMCRN are open access and freely available to anyone with an Internet C onnection and C omputer. C ast as wide a net as possible and C apture your C olleagues’ and other readers’ C uriosity. And first and foremost as a C linician: was the C are of your patient C ompetent and C ompassionate? (that is, are there any ethical concerns that may preclude peer review and publication?).

Summary and parting advice

Case reporting can be fun and a lifelong hobby, both for novice and experienced authors alike. It is now integral and widely accepted within published medical literature and today’s electronic information and data-sharing age. By following the above recommended steps and general overview, I hope to encourage BMC authors to continue to write and submit manuscripts to both JMCR and BMCRN . After your manuscript is complete, please follow the rule of “Cs”, especially “ C lear, C oncise, C oherent, C onsent, C ompassion, and C ompetence”, which will be appreciated by both reviewers and editors. Do not be afraid to obtain help from native English speakers for your manuscript. Also, please adhere to deadlines and follow instructions given by the editorial office, especially regarding any revisions. Editors read many different manuscripts and the longer it takes to get back a manuscript after revisions have been requested the less fresh that manuscript is in mind. Lastly, consider volunteering as an Associate Editor and/or reviewer within your specialty for both journals. I do for both, and the experience has improved both my writing and editing skills and daily interactions with patients.

Author information

Authors and affiliations.

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Richard A Rison

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Additional information

Competing interests.

A competing interest exists when one’s interpretation of data or presentation of information may be influenced by a personal or financial relationship with other people or organizations. Authors must disclose any financial competing interests and should also reveal any non-financial competing interests that may cause embarrassment were they to become public after the publication of the manuscript. Authors are required to complete a declaration of competing interests. All competing interests that are declared will be listed at the end of published article. Where an author gives no competing interests, the listing should read “The author(s) declare that they have no competing interests”.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-competing

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#formatting-competing

I do not usually find any problems with competing interests in the case reports that I publish, but the section should always be completed in our era and in the spirit of complete disclosure.

Authors’ contributions

In order to give appropriate credit to each author of a paper, the individual contributions of authors to the manuscript should be specified in this section.

An ‘author’ is generally considered to be someone who has made substantive intellectual contributions to a published study. To qualify as an author one should: 1) have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) have been involved in drafting the manuscript or revising it critically for important intellectual content; and 3) have given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content. Acquisition of funding, collection of data, or general supervision of the research group, alone, does not justify authorship. All contributors who do not meet the criteria for authorship should be listed in an Acknowledgements section. Examples of those who might be acknowledged include a person who provided purely technical help, writing assistance, or a department chair who provided only general support.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-contributions

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#formatting-contributions

I have found over the years a trend towards multi-authored case report manuscripts by many different individuals involved in the care of a patient(s). In my setting, it is usually me, a medical student or resident, a second-opinion tertiary colleague, and/or a pathologist or radiologist (if applicable). But I also recognize that there are situations that warrant more co-authors. The above criteria though for co-authorship should always be followed, and I have seen editorial situations where peer reviewers (including Associate Editors) have questioned what they felt was excessive authorship.

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Rison, R.A. A guide to writing case reports for the Journal of Medical Case Reports and BioMed Central Research Notes . J Med Case Reports 7 , 239 (2013). https://doi.org/10.1186/1752-1947-7-239

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Received : 30 August 2013

Accepted : 07 October 2013

Published : 27 November 2013

DOI : https://doi.org/10.1186/1752-1947-7-239

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Journals accepting case reports

Terri gotschall.

1 [email protected] , Scholarly Communications Librarian, Health Sciences Library, University of Central Florida College of Medicine, Orlando, FL.

Angela Spencer

2 [email protected] , Saint Louis University, St. Louis, MO.

Margaret A. Hoogland

3 [email protected] , Associate Professor, University Libraries, The University of Toledo, Toledo, OH.

Elisa Cortez

4 [email protected] , Medical Education and Clinical Outreach Librarian, UC Riverside Library, Orbach Science Library, University of California, Riverside, Riverside, CA.

Elizabeth Irish

5 ude.cma@ehsiri , Associate Professor, Schaffer Library of Health Sciences, Albany Medical College, Albany, NY.

Associated Data

Medical Journals that Accept Case Reports is available on Open Science Framework (OSF) under the CC-By Attribution 4.0 International Creative Commons license at https://osf.io/b9wnx .

Background:

Few resources exist to support finding journals that accept case reports by specialty. In 2016, Katherine Akers compiled a list of 160 journals that accepted case reports, which many librarians continue to use 7 years later. Because journals' editorial policies and submission guidelines evolve, finding publication venues for case reports poses a dynamic problem, consisting of reviewing a journal's author guidelines to determine if the journal accepts case report manuscripts. This project aimed to create a more up to date and extensive list of journals that currently accept case reports.

Case Presentation:

1,874 journal titles were downloaded from PubMed. The team reviewed each journal and identified journal titles that accept case reports. Additional inclusion factors included being indexed in MEDLINE, accessible on the internet, and accepting and publishing English language submissions.

Discussion:

The new journal list includes 1,028 journals covering 129 specialties and is available on the Open Science Framework public page.

Case reports are a type of article that provide a detailed account of a novel clinical finding, describing the findings, clinical progress, and future outlook of an individual patient [ 1 ]. Though the gold standard in publishing is original research, publishing a case report continues to add value to the medical literature [ 2 ]. A case report may also serve as a starting point for more complicated studies and research projects [ 3 ]. However, peer-reviewed journals in the last twenty years have become more reluctant to accept case reports as they are low on the hierarchy of evidence [ 4 ]. One example of this is the American College of Cardiology journal, which directs case reports to the Journal of the American College of Cardiology (JACC) Case Reports publication, rather than other JACC titles. JACC views case reports as an opportunity for early career cardiologists to start their publication journey but expects more experienced practitioners to publish their research within other formats [ 5 ].

The design of contemporary undergraduate medical education has reinforced the importance of case report authorship as a publishing opportunity for early career physicians. Fourth-year medical students have expressed that writing a case report improves their scientific writing and presentation skills, improves their curriculum vitae, and helps them secure residency positions [ 4 ]. The pressure on medical students to publish has increased after the transition of the United States Medical Licensing Examination (USMLE) Step 1 from a graded score to pass/fail in January 2022. This change may be one of the driving forces behind medical students seeking more opportunities to publish, as students find ways to make their residency applications stronger [ 6 ]. While the impact of the new USMLE scoring on student ranking in the National Resident Matching Program (NRMP) is too early to measure, initial results from program director surveys indicate that research will become a more important metric in residency selection [ 7 - 9 ].

Despite the availability of articles providing guidance on how to write case reports and select journals, authors are still faced with the challenge of finding a journal in their specialty that accepts case reports [ 10 - 13 ]. Consequently, librarians and informationists often receive requests from authors seeking assistance in locating journals that accept case reports. To help librarians, in 2016, Akers compiled a list of 160 journal titles that accept case reports [ 14 ]. However, the number of journals that accept case reports has grown over time. To address this need, our team aimed to create an extensive, but not exhaustive, list of journals that currently accept case reports, and make it publicly available. This list can serve as a valuable resource for authors, serving as a starting point for finding journals in their specialty, while also offering the opportunity for librarians and informationists to customize it to meet the needs of their users.

CASE PRESENTATION

Journal search.

Our team conducted a search in PubMed for journals that included the publication type “case reports.” Next, the filters for “MEDLINE” and “English” were applied. Lastly, the team used the custom date ranges from November 1, 2021, to April 30, 2022, to narrow down to journals that were currently publishing. The records were downloaded to Excel and journal titles were deduplicated.

The team chose to limit to MEDLINE journals. Indexing requirements for MEDLINE include transparent editorial policies, explicit peer review information, ethical and conflict of interest policies, and editorial board information [ 15 ]. Additionally, it is possible to search MEDLINE-using a variety of databases and search engines, which makes articles published in MEDLINE indexed journals discoverable to a wider range of potential authors who may have different access points to MEDLINE.

Journal Evaluation and Data Collection

The team collected the following information for each journal: journal title, URL to instructions to authors, and whether the journal accepts case reports. For any journal currently accepting case reports, the team collected further information about the publishing model (subscription with no author fees, subscription with author fees, open access with no fees, open access with fees, or hybrid) and selected the appropriate specialties. To facilitate data collection, the National Library of Medicine (NLM) catalog was searched for each journal, and from the journal record the electronic links were used to navigate to the journal websites. If a link was broken the team searched the internet for the journal title.

The team created a controlled vocabulary list for the specialties. For cross-disciplinary journals, the team selected all applicable specialties. For journals with unclear specialties, the team included all the assigned Medical Subject Headings (MeSH) terms listed in the NLM catalog record. Team members selected “other,” when a specialty did not appear on the list, then reviewed and updated the list as needed. Post-screening, the team finalized the specialty list.

Finally, the team used the free version of AirTable (Formagrid, Inc., San Francisco, CA), which includes an online data collection form. After compiling the data, the team uploaded the file into the Open Science Framework.

Of the 1,874 journals reviewed, the team excluded 846 titles for the following reasons:

Not fully indexed by MEDLINE (n=3)
The journal website or instructions to authors used non-English text and the team could not translate the instructions into English (n=30)
Unable to access the author instructions or broken journal websites (n=5)
The journal was no longer being published (n=2)
Non-journal publications (conference proceedings and books) (n=3)
Did not explicitly state in the author guidelines that accept case reports (n=803)

The final list includes 1,028 journals and is available in the Open Science Framework (OSF) at https://osf.io/b9wnx . Users can download the list or view it online. The spreadsheet is searchable, and users can sort the list by clicking on the column header(s).

Authors often consult librarians about where to publish articles. During a consultation or reference interview, the librarian may guide authors through finding and evaluating journals. They may help authors create their own list of criteria for a journal including manuscript types accepted, indexing, aim and scope, open access, cost to publish, or journal ranking [ 16 ]. Once an author has a list of criteria, a librarian or author will need to find journals to submit their article to, this is often a time-consuming process. Two common criteria for authors of case reports are the journal must accept case reports and the journal is indexed in MEDLINE. Having a list of journals by specialty, indexed in MEDLINE, and accepting case reports is a useful starting point for librarians and authors.

Case reports are not usually funded research projects and some authors may have to consider the cost of publishing their manuscript. Costs could vary by geographic location or the journal's agreement with an author's organization [ 17 , 18 ], though some authors have access to departmental funds to cover publishing costs. For librarians at organizations that do not provide funds, authors frequently ask for journals that are 100% free of Article Processing Charges (APCs), submission fees, page charges, and color fees. This usually leads librarians to discuss the benefits and challenges of various publishing models. By including the journal's publishing model, broken out to include open access with and without APCs, and subscription journals with and without fees, authors and librarians can quickly weed out journals by costs. Additionally, authors who want to publish their work open access can quickly determine if a journal offers a route to open access publishing.

The team intends for the list of journals available on Open Science Framework (OSF) to be customized for local use. The list can be downloaded and further curated to meet a specific user group's needs, for example by adding journals that are not indexed in MEDLINE, or by showcasing open access journals with transformative agreements with the organization. The curated list can then be uploaded and shared with a user group on the library's website.

LIMITATIONS

Journals frequently change publishing models, fee structures, and submission categories. As a result, any listing of journals that publish case reports represents at best a partial snapshot of the landscape at a given time. While this list can serve as a starting point when consulting with learners about where to publish a case study, it should not be viewed as exhaustive and may become out of date.

ACKNOWLEDGMENTS

Our team would like to thank and acknowledge Virginia Desouky, Scholarly Engagement Librarian, who assisted with identifying inclusion and exclusion criteria and screening journals.

DATA AVAILABILITY STATEMENT

Author contributions.

Terri Gotschall: conceptualization, supervision, project management, methodology, data creation, visualization, writing - original draft, writing - review and editing. Angela Spencer: conceptualization, methodology, data curation, writing - original draft, writing - review and editing. Margaret A. Hoogland: project management, resources, methodology, data curation, writing - original draft, writing - review and editing. Elisa Cortez: methodology, data curation, writing - original draft, writing - review and editing. Elizabeth Irish: methodology, data curation, writing - original draft, writing - review and editing.

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Medical Case Studies

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Artificial intelligence and medical education: application in classroom instruction and student assessment using a pharmacology & therapeutics case study

Kannan Sridharan 1 &
Reginald P. Sequeira 1

BMC Medical Education volume 24 , Article number: 431 ( 2024 ) Cite this article

Metrics details

Artificial intelligence (AI) tools are designed to create or generate content from their trained parameters using an online conversational interface. AI has opened new avenues in redefining the role boundaries of teachers and learners and has the potential to impact the teaching-learning process.

In this descriptive proof-of- concept cross-sectional study we have explored the application of three generative AI tools on drug treatment of hypertension theme to generate: (1) specific learning outcomes (SLOs); (2) test items (MCQs- A type and case cluster; SAQs; OSPE); (3) test standard-setting parameters for medical students.

Analysis of AI-generated output showed profound homology but divergence in quality and responsiveness to refining search queries. The SLOs identified key domains of antihypertensive pharmacology and therapeutics relevant to stages of the medical program, stated with appropriate action verbs as per Bloom’s taxonomy. Test items often had clinical vignettes aligned with the key domain stated in search queries. Some test items related to A-type MCQs had construction defects, multiple correct answers, and dubious appropriateness to the learner’s stage. ChatGPT generated explanations for test items, this enhancing usefulness to support self-study by learners. Integrated case-cluster items had focused clinical case description vignettes, integration across disciplines, and targeted higher levels of competencies. The response of AI tools on standard-setting varied. Individual questions for each SAQ clinical scenario were mostly open-ended. The AI-generated OSPE test items were appropriate for the learner’s stage and identified relevant pharmacotherapeutic issues. The model answers supplied for both SAQs and OSPEs can aid course instructors in planning classroom lessons, identifying suitable instructional methods, establishing rubrics for grading, and for learners as a study guide. Key lessons learnt for improving AI-generated test item quality are outlined.

Conclusions

AI tools are useful adjuncts to plan instructional methods, identify themes for test blueprinting, generate test items, and guide test standard-setting appropriate to learners’ stage in the medical program. However, experts need to review the content validity of AI-generated output. We expect AIs to influence the medical education landscape to empower learners, and to align competencies with curriculum implementation. AI literacy is an essential competency for health professionals.

Peer Review reports

Artificial intelligence (AI) has great potential to revolutionize the field of medical education from curricular conception to assessment [ 1 ]. AIs used in medical education are mostly generative AI large language models that were developed and validated based on billions to trillions of parameters [ 2 ]. AIs hold promise in the incorporation of history-taking, assessment, diagnosis, and management of various disorders [ 3 ]. While applications of AIs in undergraduate medical training are being explored, huge ethical challenges remain in terms of data collection, maintaining anonymity, consent, and ownership of the provided data [ 4 ]. AIs hold a promising role amongst learners because they can deliver a personalized learning experience by tracking their progress and providing real-time feedback, thereby enhancing their understanding in the areas they are finding difficult [ 5 ]. Consequently, a recent survey has shown that medical students have expressed their interest in acquiring competencies related to the use of AIs in healthcare during their undergraduate medical training [ 6 ].

Pharmacology and Therapeutics (P & T) is a core discipline embedded in the undergraduate medical curriculum, mostly in the pre-clerkship phase. However, the application of therapeutic principles forms one of the key learning objectives during the clerkship phase of the undergraduate medical career. Student assessment in pharmacology & therapeutics (P&T) is with test items such as multiple-choice questions (MCQs), integrated case cluster questions, short answer questions (SAQs), and objective structured practical examination (OSPE) in the undergraduate medical curriculum. It has been argued that AIs possess the ability to communicate an idea more creatively than humans [ 7 ]. It is imperative that with access to billions of trillions of datasets the AI platforms hold promise in playing a crucial role in the conception of various test items related to any of the disciplines in the undergraduate medical curriculum. Additionally, AIs provide an optimized curriculum for a program/course/topic addressing multidimensional problems [ 8 ], although robust evidence for this claim is lacking.

The existing literature has evaluated the knowledge, attitude, and perceptions of adopting AI in medical education. Integration of AIs in medical education is the need of the hour in all health professional education. However, the academic medical fraternity facing challenges in the incorporation of AIs in the medical curriculum due to factors such as inadequate grounding in data analytics, lack of high-quality firm evidence favoring the utility of AIs in medical education, and lack of funding [ 9 ]. Open-access AI platforms are available free to users without any restrictions. Hence, as a proof-of-concept, we chose to explore the utility of three AI platforms to identify specific learning objectives (SLOs) related to pharmacology discipline in the management of hypertension for medical students at different stages of their medical training.

Study design and ethics

The present study is observational, cross-sectional in design, conducted in the Department of Pharmacology & Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Kingdom of Bahrain, between April and August 2023. Ethical Committee approval was not sought given the nature of this study that neither had any interaction with humans, nor collection of any personal data was involved.

Study procedure

We conducted the present study in May-June 2023 with the Poe© chatbot interface created by Quora© that provides access to the following three AI platforms:

Sage Poe [ 10 ]: A generative AI search engine developed by Anthropic © that conceives a response based on the written input provided. Quora has renamed Sage Poe as Assistant © from July 2023 onwards.

Claude-Instant [ 11 ]: A retrieval-based AI search engine developed by Anthropic © that collates a response based on pre-written responses amongst the existing databases.

ChatGPT version 3.5 [ 12 ]: A generative architecture-based AI search engine developed by OpenAI © trained on large and diverse datasets.

We queried the chatbots to generate SLOs, A-type MCQs, integrated case cluster MCQs, integrated SAQs, and OSPE test items in the domain of systemic hypertension related to the P&T discipline. Separate prompts were used to generate outputs for pre-clerkship (preclinical) phase students, and at the time of graduation (before starting residency programs). Additionally, we have also evaluated the ability of these AI platforms to estimate the proportion of students correctly answering these test items. We used the following queries for each of these objectives:

Specific learning objectives

Can you generate specific learning objectives in the pharmacology discipline relevant to undergraduate medical students during their pre-clerkship phase related to anti-hypertensive drugs?

Can you generate specific learning objectives in the pharmacology discipline relevant to undergraduate medical students at the time of graduation related to anti-hypertensive drugs?

A-type MCQs

In the initial query used for A-type of item, we specified the domains (such as the mechanism of action, pharmacokinetics, adverse reactions, and indications) so that a sample of test items generated without any theme-related clutter, shown below:

Write 20 single best answer MCQs with 5 choices related to anti-hypertensive drugs for undergraduate medical students during the pre-clerkship phase of which 5 MCQs should be related to mechanism of action, 5 MCQs related to pharmacokinetics, 5 MCQs related to adverse reactions, and 5 MCQs should be related to indications.

The MCQs generated with the above search query were not based on clinical vignettes. We queried again to generate MCQs using clinical vignettes specifically because most medical schools have adopted problem-based learning (PBL) in their medical curriculum.

Write 20 single best answer MCQs with 5 choices related to anti-hypertensive drugs for undergraduate medical students during the pre-clerkship phase using a clinical vignette for each MCQ of which 5 MCQs should be related to the mechanism of action, 5 MCQs related to pharmacokinetics, 5 MCQs related to adverse reactions, and 5 MCQs should be related to indications.

We attempted to explore whether AI platforms can provide useful guidance on standard-setting. Hence, we used the following search query.

Can you do a simulation with 100 undergraduate medical students to take the above questions and let me know what percentage of students got each MCQ correct?

Integrated case cluster MCQs

Write 20 integrated case cluster MCQs with 2 questions in each cluster with 5 choices for undergraduate medical students during the pre-clerkship phase integrating pharmacology and physiology related to systemic hypertension with a case vignette. Please do not include ‘none of the above’ as the choice. (This modified search query was used because test items with ‘None of the above’ option were generated with the previous search query).

Write 20 integrated case cluster MCQs with 2 questions in each cluster with 5 choices for undergraduate medical students at the time of graduation integrating pharmacology and physiology related to systemic hypertension with a case vignette.

Integrated short answer questions

Write a short answer question scenario with difficult questions based on the theme of a newly diagnosed hypertensive patient for undergraduate medical students with the main objectives related to the physiology of blood pressure regulation, risk factors for systemic hypertension, pathophysiology of systemic hypertension, pathological changes in the systemic blood vessels in hypertension, pharmacological management, and non-pharmacological treatment of systemic hypertension.

Write a short answer question scenario with moderately difficult questions based on the theme of a newly diagnosed hypertensive patient for undergraduate medical students with the main objectives related to the physiology of blood pressure regulation, risk factors for systemic hypertension, pathophysiology of systemic hypertension, pathological changes in the systemic blood vessels in hypertension, pharmacological management, and non-pharmacological treatment of systemic hypertension.

Write a short answer question scenario with questions based on the theme of a newly diagnosed hypertensive patient for undergraduate medical students at the time of graduation with the main objectives related to the physiology of blood pressure regulation, risk factors for systemic hypertension, pathophysiology of systemic hypertension, pathological changes in the systemic blood vessels in hypertension, pharmacological management, and non-pharmacological treatment of systemic hypertension.

Can you generate 5 OSPE pharmacology and therapeutics prescription writing exercises for the assessment of undergraduate medical students at the time of graduation related to anti-hypertensive drugs?

Can you generate 5 OSPE pharmacology and therapeutics prescription writing exercises containing appropriate instructions for the patients for the assessment of undergraduate medical students during their pre-clerkship phase related to anti-hypertensive drugs?

Can you generate 5 OSPE pharmacology and therapeutics prescription writing exercises containing appropriate instructions for the patients for the assessment of undergraduate medical students at the time of graduation related to anti-hypertensive drugs?

Both authors independently evaluated the AI-generated outputs, and a consensus was reached. We cross-checked the veracity of answers suggested by AIs as per the Joint National Commission Guidelines (JNC-8) and Goodman and Gilman’s The Pharmacological Basis of Therapeutics (2023), a reference textbook [ 13 , 14 ]. Errors in the A-type MCQs were categorized as item construction defects, multiple correct answers, and uncertain appropriateness to the learner’s level. Test items in the integrated case cluster MCQs, SAQs and OSPEs were evaluated with the Preliminary Conceptual Framework for Establishing Content Validity of AI-Generated Test Items based on the following domains: technical accuracy, comprehensiveness, education level, and lack of construction defects (Table 1 ). The responses were categorized as complete and deficient for each domain.

The pre-clerkship phase SLOs identified by Sage Poe, Claude-Instant, and ChatGPT are listed in the electronic supplementary materials 1 – 3 , respectively. In general, a broad homology in SLOs generated by the three AI platforms was observed. All AI platforms identified appropriate action verbs as per Bloom’s taxonomy to state the SLO; action verbs such as describe, explain, recognize, discuss, identify, recommend, and interpret are used to state the learning outcome. The specific, measurable, achievable, relevant, time-bound (SMART) SLOs generated by each AI platform slightly varied. All key domains of antihypertensive pharmacology to be achieved during the pre-clerkship (pre-clinical) years were relevant for graduating doctors. The SLOs addressed current JNC Treatment Guidelines recommended classes of antihypertensive drugs, the mechanism of action, pharmacokinetics, adverse effects, indications/contraindications, dosage adjustments, monitoring therapy, and principles of monotherapy and combination therapy.

The SLOs to be achieved by undergraduate medical students at the time of graduation identified by Sage Poe, Claude-Instant, and ChatGPT listed in electronic supplementary materials 4 – 6 , respectively. The identified SLOs emphasize the application of pharmacology knowledge within a clinical context, focusing on competencies needed to function independently in early residency stages. These SLOs go beyond knowledge recall and mechanisms of action to encompass competencies related to clinical problem-solving, rational prescribing, and holistic patient management. The SLOs generated require higher cognitive ability of the learner: action verbs such as demonstrate, apply, evaluate, analyze, develop, justify, recommend, interpret, manage, adjust, educate, refer, design, initiate & titrate were frequently used.

The MCQs for the pre-clerkship phase identified by Sage Poe, Claude-Instant, and ChatGPT listed in the electronic supplementary materials 7 – 9 , respectively, and those identified with the search query based on the clinical vignette in electronic supplementary materials ( 10 – 12 ).

All MCQs generated by the AIs in each of the four domains specified [mechanism of action (MOA); pharmacokinetics; adverse drug reactions (ADRs), and indications for antihypertensive drugs] are quality test items with potential content validity. The test items on MOA generated by Sage Poe included themes such as renin-angiotensin-aldosterone (RAAS) system, beta-adrenergic blockers (BB), calcium channel blockers (CCB), potassium channel openers, and centrally acting antihypertensives; on pharmacokinetics included high oral bioavailability/metabolism in liver [angiotensin receptor blocker (ARB)-losartan], long half-life and renal elimination [angiotensin converting enzyme inhibitors (ACEI)-lisinopril], metabolism by both liver and kidney (beta-blocker (BB)-metoprolol], rapid onset- short duration of action (direct vasodilator-hydralazine), and long-acting transdermal drug delivery (centrally acting-clonidine). Regarding the ADR theme, dry cough, angioedema, and hyperkalemia by ACEIs in susceptible patients, reflex tachycardia by CCB/amlodipine, and orthostatic hypotension by CCB/verapamil addressed. Clinical indications included the drug of choice for hypertensive patients with concomitant comorbidity such as diabetics (ACEI-lisinopril), heart failure and low ejection fraction (BB-carvedilol), hypertensive urgency/emergency (alpha cum beta receptor blocker-labetalol), stroke in patients with history recurrent stroke or transient ischemic attack (ARB-losartan), and preeclampsia (methyldopa).

Almost similar themes under each domain were identified by the Claude-Instant AI platform with few notable exceptions: hydrochlorothiazide (instead of clonidine) in MOA and pharmacokinetics domains, respectively; under the ADR domain ankle edema/ amlodipine, sexual dysfunction and fatigue in male due to alpha-1 receptor blocker; under clinical indications the best initial monotherapy for clinical scenarios such as a 55-year old male with Stage-2 hypertension; a 75-year-old man Stage 1 hypertension; a 35-year-old man with Stage I hypertension working on night shifts; and a 40-year-old man with stage 1 hypertension and hyperlipidemia.

As with Claude-Instant AI, ChatGPT-generated test items on MOA were mostly similar. However, under the pharmacokinetic domain, immediate- and extended-release metoprolol, the effect of food to enhance the oral bioavailability of ramipril, and the highest oral bioavailability of amlodipine compared to other commonly used antihypertensives were the themes identified. Whereas the other ADR themes remained similar, constipation due to verapamil was a new theme addressed. Notably, in this test item, amlodipine was an option that increased the difficulty of this test item because amlodipine therapy is also associated with constipation, albeit to a lesser extent, compared to verapamil. In the clinical indication domain, the case description asking “most commonly used in the treatment of hypertension and heart failure” is controversial because the options listed included losartan, ramipril, and hydrochlorothiazide but the suggested correct answer was ramipril. This is a good example to stress the importance of vetting the AI-generated MCQ by experts for content validity and to assure robust psychometrics. The MCQ on the most used drug in the treatment of “hypertension and diabetic nephropathy” is more explicit as opposed to “hypertension and diabetes” by Claude-Instant because the therapeutic concept of reducing or delaying nephropathy must be distinguished from prevention of nephropathy, although either an ACEI or ARB is the drug of choice for both indications.

It is important to align student assessment to the curriculum; in the PBL curriculum, MCQs with a clinical vignette are preferred. The modification of the query specifying the search to generate MCQs with a clinical vignette on domains specified previously gave appropriate output by all three AI platforms evaluated (Sage Poe; Claude- Instant; Chat GPT). The scenarios generated had a good clinical fidelity and educational fit for the pre-clerkship student perspective.

The errors observed with AI outputs on the A-type MCQs are summarized in Table 2 . No significant pattern was observed except that Claude-Instant© generated test items in a stereotyped format such as the same choices for all test items related to pharmacokinetics and indications, and all the test items in the ADR domain are linked to the mechanisms of action of drugs. This illustrates the importance of reviewing AI-generated test items by content experts for content validity to ensure alignment with evidence-based medicine and up-to-date treatment guidelines.

The test items generated by ChatGPT had the advantage of explanations supplied rendering these more useful for learners to support self-study. The following examples illustrate this assertion: “ A patient with hypertension is started on a medication that works by blocking beta-1 receptors in the heart (metoprolol)”. Metoprolol is a beta blocker that works by blocking beta-1 receptors in the heart, which reduces heart rate and cardiac output, resulting in a decrease in blood pressure. However, this explanation is incomplete because there is no mention of other less important mechanisms, of beta receptor blockers on renin release. Also, these MCQs were mostly recall type: Which of the following medications is known to have a significant first-pass effect? The explanation reads: propranolol is known to have a significant first pass-effect, meaning that a large portion of the drug is metabolized by the liver before it reaches systemic circulation. Losartan, amlodipine, ramipril, and hydrochlorothiazide do not have significant first-pass effect. However, it is also important to extend the explanation further by stating that the first-pass effect of propranolol does not lead to total loss of pharmacological activity because the metabolite hydroxy propranolol also has potent beta-blocking activity. Another MCQ test item had a construction defect: “A patient with hypertension is started on a medication that can cause photosensitivity. Which of the following medications is most likely responsible?” Options included: losartan, amlodipine, ramipril, hydrochlorothiazide, hydrochlorothiazide/triamterene. The explanation states that hydrochlorothiazide (HCTZ) can cause photosensitivity, which is increased sensitivity to sunlight that can cause skin rashes and sunburns. Losartan, amlodipine, ramipril, and HCTZ/triamterene are less likely to cause photosensitivity. However, it is irrational to claim that HCTZ/triamterene, one of the wrong options, is less likely to cause photosensitivity. The difficulty index of such test items is likely unacceptable in high-stake tests to make equitable psychometric decisions.

The responses from Sage Poe, Claude-Instant, and ChatGPT on guidance for standard-setting methods are listed in the electronic supplementary materials 13 – 15 . Sage Poe offered this information with the caveat that “the results of this simulation were purely hypothetical and do not reflect the actual performance of any real students”. The simulation estimates of examinees correctly answering test items ranged from 60 to 90% for the mechanism of action, 65–85% for pharmacokinetics, 60–80% for adverse reactions, and 75–90% for clinical indications of antihypertensives.

In contrast, Claude-Instant admitted that “Performing a full simulation with 100 medical students is beyond the scope of what I can do as an AI assistant. I can generate sample MCQ questions and answers, but I do not have access to a population of medical students to administer the questions. A true simulation that administers questions to real students and analyzes the results would require access to a database of medical students, a platform to deliver the questions, and code to analyze the responses. As an AI assistant, I lack these capabilities. While I cannot perform a full simulation, here are some considerations for administering MCQ questions to medical students: provide details on the purpose and instructions for the test to ensure students understand what is expected out of them; consider including some easier questions in addition to more challenging ones to boost students’ confidence and motivation; avoid ambiguous wording and ensure each question has only one unambiguously correct answer option; when analyzing results, look for questions factors that may have impacted performance, like unclear wording or answer options that are too similar. Focusing on weak questions can help improve future tests; compare performance across different student groups to identify areas where more teaching may be needed; provide detailed answer explanations and review sessions after the test to help students learn from any errors and reinforce correct concepts”. However, ChatGPT offered the simulation result estimates for the 20 MCQ on antihypertensive drugs: mechanism of action ranged from 67 to 92%, pharmacokinetics 63–86%, adverse effects 65–82%, and clinical indications 64–89%. Furthermore, it also stated that “Overall, the performance of the students was quite good, with most questions having a response rate of over 70%. However, there were some questions where the projected correct response rate was rather low, such as Question #5 (Mechanism of Action of Hydrochlorothiazide; see Electronic Supplementary Material 12 ) and Question 18 (Indications for Verapamil; see Electronic Supplementary Material 10 ). This may suggest areas where students need more focused education or review.”

We asked AI assistants to generate 20 integrated case cluster MCQs with 2 test items in each cluster with five options for undergraduate medical students in the pre-clerkship phase integrating pharmacology and physiology related to systemic hypertension with a case vignette and the responses by Sage Poe, Claude-Instant, and ChatGPT are listed in the electronic supplementary materials ( 16 – 18 ). In all instances, the test items generated had focused case descriptions in the form of a clinical vignette, and horizontal integration across the pathophysiology of hypertension and pharmacology of antihypertensive drugs. These test items mostly targeted the ‘knows (knowledge)’ or ‘knows how (competence)’ level on Miller’s pyramid and are suitable for assessing the clinical competence of pre-clerkship medical students, especially in an integrated PBL curriculum. Both the AI assistants generated excellent clinical vignettes and themes; however, most of the cluster MCQs by ChatGPT had “None of the above” as an option, which is often considered a test item construction flaw. Notwithstanding these limitations, case cluster integrated test items are valuable for learners to integrate their knowledge of different basic medical sciences and their application to clinical sciences. This integrated approach can be used for both instructional and student assessment purposes to make the course more meaningful. Indeed, one of the basic tenets of PBL is curriculum integration.

In the next query, we asked AI assistants to write integrated case cluster MCQs with 2 test items in each cluster with 5 options for undergraduate medical students at the time of graduation integrating pharmacology and physiology of hypertension with a case vignette. The responses are listed in the electronic supplementary materials 19 – 21 . Claude-Instant has provided only partial responses to both the queries. Overall, the information provided in case vignettes requires the learner to interpret the clinical information and make therapeutic decisions. Such test items are appropriate for assessing the minimum competency of medical school graduates to start internship or residency programs; these MCQs are generally comparable to test items used in USMLE Part 2. The evaluation of the integrated case cluster test items provided by all the AI platforms is summarized in Table 3 . In general, the AI outputs had at least one construction defect, and did not include all the core sub-topics to a sufficient degree.

When asked to simulate the above-generated test items to 100 undergraduate medical students at the time of graduation and provide a percentage of students who are likely to correctly answer each item, the AI assistant responded:

“ As an AI language model, I cannot simulate the responses of 100 undergraduate medical students likely to obtain the correct answer for each question. However, I can provide some general information about the difficulty level of each question based on the complexity of the concepts being tested and the level of integration between pharmacology and physiology ”.

AI assistant went on to clarify that questions that require knowledge of basic pharmacology principles, such as the mechanism of action of specific drugs, are likely to be easier for students to answer correctly. Test items that require an understanding of the physiological mechanisms underlying hypertension and correlating with symptoms are likely to be more challenging for students. The AI assistant sorted these test items into two categories accordingly. Overall, the difficulty level of the test item is based on the level of integration between pharmacology and pathophysiology. Test items that require an understanding of both pharmacological and physiological mechanisms are likely to be more challenging for students requiring a strong foundation in both pharmacology and physiology concepts to be able to correctly answer integrated case-cluster MCQs.

Short answer questions

The responses to a search query on generating SAQs appropriate to the pre-clerkship phase Sage Poe, Claude-Instant, and ChatGPT generated items are listed in the electronic supplementary materials 22 – 24 for difficult questions and 25–27 for moderately difficult questions.

It is apparent from these case vignette descriptions that the short answer question format varied. Accordingly, the scope for asking individual questions for each scenario is open-ended. In all instances, model answers are supplied which are helpful for the course instructor to plan classroom lessons, identify appropriate instructional methods, and establish rubrics for grading the answer scripts, and as a study guide for students.

We then wanted to see to what extent AI can differentiate the difficulty of the SAQ by replacing the search term “difficult” with “moderately difficult” in the above search prompt: the changes in the revised case scenarios are substantial. Perhaps the context of learning and practice (and the level of the student in the MD/medical program) may determine the difficulty level of SAQ generated. It is worth noting that on changing the search from cardiology to internal medicine rotation in Sage Poe the case description also changed. Thus, it is essential to select an appropriate AI assistant, perhaps by trial and error, to generate quality SAQs. Most of the individual questions tested stand-alone knowledge and did not require students to demonstrate integration.

The responses of Sage Poe, Claude-Instant, and ChatGPT for the search query to generate SAQs at the time of graduation are listed in the electronic supplementary materials 28 – 30 . It is interesting to note how AI assistants considered the stage of the learner while generating the SAQ. The response by Sage Poe is illustrative for comparison. “You are a newly graduated medical student who is working in a hospital” versus “You are a medical student in your pre-clerkship.”

Some questions were retained, deleted, or modified to align with competency appropriate to the context (Electronic Supplementary Materials 28 – 30 ). Overall, the test items at both levels from all AI platforms were technically accurate and thorough addressing the topics related to different disciplines (Table 3 ). The differences in learning objective transition are summarized in Table 4 . A comparison of learning objectives revealed that almost all objectives remained the same except for a few (Table 5 ).

A similar trend was apparent with test items generated by other AI assistants, such as ChatGPT. The contrasting differences in questions are illustrated by the vertical integration of basic sciences and clinical sciences (Table 6 ).

Taken together, these in-depth qualitative comparisons suggest that AI assistants such as Sage Poe and ChatGPT consider the learner’s stage of training in designing test items, learning outcomes, and answers expected from the examinee. It is critical to state the search query explicitly to generate quality output by AI assistants.

The OSPE test items generated by Claude-Instant and ChatGPT appropriate to the pre-clerkship phase (without mentioning “appropriate instructions for the patients”) are listed in the electronic supplementary materials 31 and 32 and with patient instructions on the electronic supplementary materials 33 and 34 . For reasons unknown, Sage Poe did not provide any response to this search query.

The five OSPE items generated were suitable to assess the prescription writing competency of pre-clerkship medical students. The clinical scenarios identified by the three AI platforms were comparable; these scenarios include patients with hypertension and impaired glucose tolerance in a 65-year-old male, hypertension with chronic kidney disease (CKD) in a 55-year-old woman, resistant hypertension with obstructive sleep apnea in a 45-year-old man, and gestational hypertension at 32 weeks in a 35-year-old (Claude-Instant AI). Incorporating appropriate instructions facilitates the learner’s ability to educate patients and maximize safe and effective therapy. The OSPE item required students to write a prescription with guidance to start conservatively, choose an appropriate antihypertensive drug class (drug) based on the patients’ profile, specifying drug name, dose, dosing frequency, drug quantity to be dispensed, patient name, date, refill, and caution as appropriate, in addition to prescribers’ name, signature, and license number. In contrast, ChatGPT identified clinical scenarios to include patients with hypertension and CKD, hypertension and bronchial asthma, gestational diabetes, hypertension and heart failure, and hypertension and gout (ChatGPT). Guidance for dosage titration, warnings to be aware, safety monitoring, and frequency of follow-up and dose adjustment. These test items are designed to assess learners’ knowledge of P & T of antihypertensives, as well as their ability to provide appropriate instructions to patients. These clinical scenarios for writing prescriptions assess students’ ability to choose an appropriate drug class, write prescriptions with proper labeling and dosing, reflect drug safety profiles, and risk factors, and make modifications to meet the requirements of special populations. The prescription is required to state the drug name, dose, dosing frequency, patient name, date, refills, and cautions or instructions as needed. A conservative starting dose, once or twice daily dosing frequency based on the drug, and instructions to titrate the dose slowly if required.

The responses from Claude-Instant and ChatGPT for the search query related to generating OSPE test items at the time of graduation are listed in electronic supplementary materials 35 and 36 . In contrast to the pre-clerkship phase, OSPEs generated for graduating doctors’ competence assessed more advanced drug therapy comprehension. For example, writing a prescription for:

(1) A 65-year- old male with resistant hypertension and CKD stage 3 to optimize antihypertensive regimen required the answer to include starting ACEI and diuretic, titrating the dosage over two weeks, considering adding spironolactone or substituting ACEI with an ARB, and need to closely monitor serum electrolytes and kidney function closely.

(2) A 55-year-old woman with hypertension and paroxysmal arrhythmia required the answer to include switching ACEI to ARB due to cough, adding a CCB or beta blocker for rate control needs, and adjusting the dosage slowly and monitoring for side effects.

(3) A 45-year-old man with masked hypertension and obstructive sleep apnea require adding a centrally acting antihypertensive at bedtime and increasing dosage as needed based on home blood pressure monitoring and refer to CPAP if not already using one.

(4) A 75-year-old woman with isolated systolic hypertension and autonomic dysfunction to require stopping diuretic and switching to an alpha blocker, upward dosage adjustment and combining with other antihypertensives as needed based on postural blood pressure changes and symptoms.

(5) A 35-year-old pregnant woman with preeclampsia at 29 weeks require doubling methyldopa dose and consider adding labetalol or nifedipine based on severity and educate on signs of worsening and to follow-up immediately for any concerning symptoms.

These case scenarios are designed to assess the ability of the learner to comprehend the complexity of antihypertensive regimens, make evidence-based regimen adjustments, prescribe multidrug combinations based on therapeutic response and tolerability, monitor complex patients for complications, and educate patients about warning signs and follow-up.

A similar output was provided by ChatGPT, with clinical scenarios such as prescribing for patients with hypertension and myocardial infarction; hypertension and chronic obstructive pulmonary airway disease (COPD); hypertension and a history of angina; hypertension and a history of stroke, and hypertension and advanced renal failure. In these cases, wherever appropriate, pharmacotherapeutic issues like taking ramipril after food to reduce side effects such as giddiness; selection of the most appropriate beta-blocker such as nebivolol in patients with COPD comorbidity; the importance of taking amlodipine at the same time every day with or without food; preference for telmisartan among other ARBs in stroke; choosing furosemide in patients with hypertension and edema and taking the medication with food to reduce the risk of gastrointestinal adverse effect are stressed.

The AI outputs on OSPE test times were observed to be technically accurate, thorough in addressing core sub-topics suitable for the learner’s level and did not have any construction defects (Table 3 ). Both AIs provided the model answers with explanatory notes. This facilitates the use of such OSPEs for self-assessment by learners for formative assessment purposes. The detailed instructions are helpful in creating optimized therapy regimens, and designing evidence-based regimens, to provide appropriate instructions to patients with complex medical histories. One can rely on multiple AI sources to identify, shortlist required case scenarios, and OSPE items, and seek guidance on expected model answers with explanations. The model answer guidance for antihypertensive drug classes is more appropriate (rather than a specific drug of a given class) from a teaching/learning perspective. We believe that these scenarios can be refined further by providing a focused case history along with relevant clinical and laboratory data to enhance clinical fidelity and bring a closer fit to the competency framework.

In the present study, AI tools have generated SLOs that comply with the current principles of medical education [ 15 ]. AI tools are valuable in constructing SLOs and so are especially useful for medical fraternities where training in medical education is perceived as inadequate, more so in the early stages of their academic career. Data suggests that only a third of academics in medical schools have formal training in medical education [ 16 ] which is a limitation. Thus, the credibility of alternatives, such as the AIs, is evaluated to generate appropriate course learning outcomes.

We observed that the AI platforms in the present study generated quality test items suitable for different types of assessment purposes. The AI-generated outputs were similar with minor variation. We have used generative AIs in the present study that could generate new content from their training dataset [ 17 ]. Problem-based and interactive learning approaches are referred to as “bottom-up” where learners obtain first-hand experience in solving the cases first and then indulge in discussion with the educators to refine their understanding and critical thinking skills [ 18 ]. We suggest that AI tools can be useful for this approach for imparting the core knowledge and skills related to Pharmacology and Therapeutics to undergraduate medical students. A recent scoping review evaluating the barriers to writing quality test items based on 13 studies has concluded that motivation, time constraints, and scheduling were the most common [ 19 ]. AI tools can be valuable considering the quick generation of quality test items and time management. However, as observed in the present study, the AI-generated test items nevertheless require scrutiny by faculty members for content validity. Moreover, it is important to train faculty in AI technology-assisted teaching and learning. The General Medical Council recommends taking every opportunity to raise the profile of teaching in medical schools [ 20 ]. Hence, both the academic faculty and the institution must consider investing resources in AI training to ensure appropriate use of the technology [ 21 ].

The AI outputs assessed in the present study had errors, particularly with A-type MCQs. One notable observation was that often the AI tools were unable to differentiate the differences between ACEIs and ARBs. AI platforms access several structured and unstructured data, in addition to images, audio, and videos. Hence, the AI platforms can commit errors due to extracting details from unauthenticated sources [ 22 ] created a framework identifying 28 factors for reconstructing the path of AI failures and for determining corrective actions. This is an area of interest for AI technical experts to explore. Also, this further iterates the need for human examination of test items before using them for assessment purposes.

There are concerns that AIs can memorize and provide answers from their training dataset, which they are not supposed to do [ 23 ]. Hence, the use of AIs-generated test items for summative examinations is debatable. It is essential to ensure and enhance the security features of AI tools to reduce or eliminate cross-contamination of test items. Researchers have emphasized that AI tools will only reach their potential if developers and users can access full-text non-PDF formats that help machines comprehend research papers and generate the output [ 24 ].

AI platforms may not always have access to all standard treatment guidelines. However, in the present study, it was observed that all three AI platforms generally provided appropriate test items regarding the choice of medications, aligning with recommendations from contemporary guidelines and standard textbooks in pharmacology and therapeutics. The prompts used in the study were specifically focused on the pre-clerkship phase of the undergraduate medical curriculum (and at the time of their graduation) and assessed fundamental core concepts, which were also reflected in the AI outputs. Additionally, the recommended first-line antihypertensive drug classes have been established for several decades, and information regarding their pharmacokinetics, ADRs, and indications is well-documented in the literature.

Different paradigms and learning theories have been proposed to support AI in education. These paradigms include AI- directed (learner as recipient), AI-supported (learner as collaborator), and AI-empowered (learner as leader) that are based on Behaviorism, Cognitive-Social constructivism, and Connectivism-Complex adaptive systems, respectively [ 25 ]. AI techniques have potential to stimulate and advance instructional and learning sciences. More recently a three- level model that synthesizes and unifies existing learning theories to model the roles of AIs in promoting learning process has been proposed [ 26 ]. The different components of our study rely upon these paradigms and learning theories as the theoretical underpinning.

Strengths and limitations

To the best of our knowledge, this is the first study evaluating the utility of AI platforms in generating test items related to a discipline in the undergraduate medical curriculum. We have evaluated the AI’s ability to generate outputs related to most types of assessment in the undergraduate medical curriculum. The key lessons learnt for improving the AI-generated test item quality from the present study are outlined in Table 7 . We used a structured framework for assessing the content validity of the test items. However, we have demonstrated using a single case study (hypertension) as a pilot experiment. We chose to evaluate anti-hypertensive drugs as it is a core learning objective and one of the most common disorders relevant to undergraduate medical curricula worldwide. It would be interesting to explore the output from AI platforms for other common (and uncommon/region-specific) disorders, non-/semi-core objectives, and disciplines other than Pharmacology and Therapeutics. An area of interest would be to look at the content validity of the test items generated for different curricula (such as problem-based, integrated, case-based, and competency-based) during different stages of the learning process. Also, we did not attempt to evaluate the generation of flowcharts, algorithms, or figures for generating test items. Another potential area for exploring the utility of AIs in medical education would be repeated procedural practices such as the administration of drugs through different routes by trainee residents [ 27 ]. Several AI tools have been identified for potential application in enhancing classroom instructions and assessment purposes pending validation in prospective studies [ 28 ]. Lastly, we did not administer the AI-generated test items to students and assessed their performance and so could not comment on the validity of test item discrimination and difficulty indices. Additionally, there is a need to confirm the generalizability of the findings to other complex areas in the same discipline as well as in other disciplines that pave way for future studies. The conceptual framework used in the present study for evaluating the AI-generated test items needs to be validated in a larger population. Future studies may also try to evaluate the variations in the AI outputs with repetition of the same queries.

Notwithstanding ongoing discussions and controversies, AI tools are potentially useful adjuncts to optimize instructional methods, test blueprinting, test item generation, and guidance for test standard-setting appropriate to learners’ stage in the medical program. However, experts need to critically review the content validity of AI-generated output. These challenges and caveats are to be addressed before the use of widespread use of AIs in medical education can be advocated.

Data availability

All the data included in this study are provided as Electronic Supplementary Materials.

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Sridharan, K., Sequeira, R.P. Artificial intelligence and medical education: application in classroom instruction and student assessment using a pharmacology & therapeutics case study. BMC Med Educ 24 , 431 (2024). https://doi.org/10.1186/s12909-024-05365-7

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Received : 26 September 2023

Accepted : 28 March 2024

Published : 22 April 2024

DOI : https://doi.org/10.1186/s12909-024-05365-7

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Journal of Medical Case Reports will consider any original case report that expands the field of general medical knowledge, and original research relating to case reports. Case reports should show one of the following: Unreported or unusual side effects or adverse interactions involving medications. Unexpected or unusual presentations of a disease.
Oxford Medical Case Reports
Oxford Medical Case Reports (OMCR) is an open access, peer-reviewed online journal publishing original and educationally valuable case reports that expand the field of medicine. Learn more today.
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A journal publishing case reports in all medical disciplines, including general medicine, drug interaction and adverse reactions. The largest online collection of medical case reports. Validation period: 4/22/2024, 10:35:40 AM - 4/22/2024, 4:35:40 PM. Subscribe Login.
SAGE Open Medical Case Reports: Sage Journals
SAGE Open Medical Case Reports is a peer-reviewed, open access journal, which focusses on providing a publication home for short case reports and case series, which often do not find a place in traditional primary research journals, but provide key insights into real medical cases that are essential for physicians, and may ultimately help to improve patient outcomes.
How to choose the best journal for your case report
Some of the new journals cover general medicine and others cover specific therapeutic areas. Most case report journals (94%) are open access and approximately 40% are indexed in PubMed. Clinical issues covered by case report journals include previously unreported adverse effects of drugs or other treatments, unexpected events that occur in the ...
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Post-radiation lichen planus: a case report and review of the literature. Lichen planus is a T-cell mediated inflammatory disorder of the skin and mucus membranes and is a rare complication of external beam radiation. Adam N. Musick, Do Young Kim and Steven J. Baumrucker. Journal of Medical Case Reports 2024 18 :195.
How to choose the best journal for your case report
Since the establishment of the Journal of Medical Case Reports in 2006, the number of journals that publish case reports has increased rapidly, and most of these journals are open access. Open access publishing usually requires authors to pay publication fees while offering the articles online, free of charge, and free of most copyright and licensing restrictions.
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Renal medicine. Respiratory medicine. Rheumatology. Sexual health. Sports and exercise medicine. Surgery. Urology. A journal publishing case reports in all medical disciplines, including general medicine, drug interaction and adverse reactions. The largest online collection of medical case reports.
How to write a medical case report
Writing a case report is an excellent way of documenting these findings for the wider medical community—sharing new knowledge that will lead to better and safer patient care. For many medical students and junior doctors, a case report may be their first attempt at medical writing. A published case report will look impressive on your ...
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Case 7-2024: A 67-Year-Old Woman with Alternating Sixth Cranial Nerve Palsy. J.M. Yinh and OthersN Engl J Med 2024;390:843-851. A 67-year-old woman was evaluated because of headache and retro ...
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Clinical Case Reports is inviting applications for the role of Associate Editor (Veterinary Science). We are excited to be seeking an Associate Editor to build on the journal's strong foundations and continue to develop Clinical Case Reports as a core community resource. The deadline for applications is June 15 th 2024.Please click here for further details about the role and how to apply.
New journals for publishing medical case reports
As of mid-2015, at least 160 case reports journals from 78 publishers are in existence ( Table 1, online only ), with more launching each month. Some of these journals are general medical journals (e.g., BioMed Central's Journal of Medical Case Reports, BMJ Publishing Group's BMJ Case Reports, Wiley's Clinical Case Reports ), and others serve ...
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Editorial. Introduction. Case reports and case series or case study research are descriptive studies to present patients in their natural clinical setting. Case reports, which generally consist of three or fewer patients, are prepared to illustrate features in the practice of medicine and potentially create new research questions that may contribute to the acquisition of additional knowledge ...
Guidelines To Writing A Clinical Case Report
The abstract should summarize the case, the problem it addresses, and the message it conveys. Abstracts of case studies are usually very short, preferably not more than 150 words. ... A A guide to writing case reports for the Journal of Medical Case Reports and BioMed Central Research Notes. J Med Case Rep. 2013; 7:239. Published online 2013 ...
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Journal of Medical Cases, monthly, ISSN 1923-4155 (print), 1923-4163 (online), published by Elmer Press Inc. The content of this site is intended for health care professionals. This is an open-access journal distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which permits unrestricted
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Case 17-2020: A 68-Year-Old Man with Covid-19 and Acute Kidney Injury
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Randall Cox. Ateka A. Contractor. Preview abstract. Free access Research article First published August 11, 2021 pp. 61-81. xml PDF / EPUB. Table of contents for Clinical Case Studies, 21, 1, Feb 01, 2022.
A guide to writing case reports for the Journal of Medical Case Reports
Case reports are a time-honored, important, integral, and accepted part of the medical literature. Both the Journal of Medical Case Reports and the Case Report section of BioMed Central Research Notes are committed to case report publication, and each have different criteria. Journal of Medical Case Reports was the world's first international, PubMed-listed medical journal devoted to ...
Journals accepting case reports
BACKGROUND. Case reports are a type of article that provide a detailed account of a novel clinical finding, describing the findings, clinical progress, and future outlook of an individual patient [].Though the gold standard in publishing is original research, publishing a case report continues to add value to the medical literature [].A case report may also serve as a starting point for more ...
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July-December 2023 - Vol 12 Num. 1. Tuberculous meningitis is a severe manifestation of extrapulmonary tuberculosis, often associated with substantial morbidity and mortality. This case report discusses a unique presentation of tuberculous meningitis in a 39-year-old male who was concurrently positive for COVID-19.
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Juniper Online Journal of Case Studies. Journal of Case reports is an international, peer reviewed open access journal, focussed on bringing out premium quality case reports in all areas of basic medical sciences and clinical specialities. 'JOJCS' aims to serve as a repository of medical case reports that can go a long way in enriching the ...
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Deep learning has profoundly influenced various domains, particularly medical image analysis. Traditional transfer learning approaches in this field rely on models pretrained on domain-specific medical datasets, which limits their generalizability and accessibility. In this study, we propose a novel framework called real-world feature transfer learning, which utilizes backbone models initially ...