In defence of the case report

During his ten years as Editor, Greg Wilkinson worked hard to produce a modern, polished journal with an impressive international reputation. In his valedictory editorial (Wilkinson, 2003) he sets out the goals he has pursued. Almost by definition, an editor cannot receive universal approbation. However, while I suspect that academic/research colleagues will have been happy with his stewardship, many clinicians are likely to have some reservations. The reason for this will be found in three lines in the middle of his final editorial: ‘I hastened the demise of the case report, to exclude what I see as psychiatric trivia. I published original research...’.

This is a cameo of the polarity that exists between academic, research-oriented psychiatrists and those clinicians who provide the bulk of the service in the National Health Service. They confirm the contemporary ethos that the only worth-while form of study is that of groups. The nomothetic approach takes precedence while the detailed study of an individual patient is marginalised as trivia.

Psychiatry is not unique in having been seduced by the scientific process. Unfortunately, it is doubtful how much the practice of our discipline has gained from this development (Shooter, 2003; Wilkinson, 2003). This is not surprising. Psychiatry is a discipline in which the information is ‘soft’ and much of it subjective. In contrast, the scientific approach insists that any parameter of illness that cannot be measured in terms of hard data is suspect.

As academic psychiatrists have become more influential within the profession and training is more university based, research and related activity are seen as the acme of psychiatric work. Working closely with patients and creating enduring therapeutic relationships is not valued and is sometimes seen as drudgery. This is a damning paradox. Is it surprising that it is hard to recruit into psychiatry – a specialty that is dismissive of the very core of its professional ethic?

Psychiatry needs to return to its core values (Simms, 2003). It needs to place the care and treatment of the individual patient centre-stage. Students, young doctors and psychiatric trainees must see at first hand the fascination and reward of working with patients, and see that the work is attractive and satisfying. A part of this process must be the rehabilitation of the detailed case report.