Observing the human condition: letters and case reports

Thomas J. Papadimos, MD, MPH
The Ohio State University Wexner Medical Center, Columbus, United States (Winter 2013)
From time to time medical students and residents ask me to mentor them in regard to the exploration of a research topic. My retort is that I do not consider myself a researcher, even though I engage in scholarly endeavors. I tell them that I am a writer, and emphasize that to write successfully one needs to have a reasonably good command of the English language and a bit of the DNA of a playwright. In order to write a letter or a case report, you not only need to have a penchant for spinning a good yarn, but also an inimitable ability to tell your yarn clearly, concisely, and in good order.Why do I write? I am addicted to it. As a child, I wrote about imaginary things and characters. Later on, I wrote about things I read and observed. I became an acute observer of the human condition. In 1958 Hannah Arendt wrote The Human Condition, a historical look at modernity.1 Arendt made pointed observations about human kind. This exceptional scholarly work influenced me substantially. Arendt thrilled me with her concept of man’s space of appearance. The space of appearance is “where I appear to others as others appear to me, where men exist not merely like other living or inanimate things, but to make their appearance explicitly.”1 This space is recreated “wherever men are together in the manner of speech and action.”1 We are all in some space at every point in time. Here we partake of discourses, political, social, or otherwise.It dawned on me that my story, as a physician, had stories within it. As an anesthesiologist, I work at the head of the operating room table, a great vantage point of the action within that “space.” I have seen amazing things: great feats of skill, fortunate and unfortunate matters of chance, great joys and great defeats, graceful exits and dastardly escapes. The social, economic, and sometimes political dilemmas that distress my colleagues and patients have not been lost on me. Additionally, I am an intensivist, allowing me a privileged view into the criticality of my patients and their families’ responses. This action in my “space of appearance” has allowed me, or caused me, to comment on my surroundings.

Writing a letter to the editor or a case report is the telling of a story (and remember always to tell the truth—with appropriate permissions). Allow me to introduce the concept of the case report/letter to the editor from a simplistic perspective, an important panorama from which to view such a literary effort: the fairy tale.

The introduction. “Once upon a time. . .” What has happened throughout the land, and ever after? What lesson will we learn?

The report. What happened to Snow White? How tall was she, how heavy was she, what did she imbibe and ingest, and what happened to her? How do you know what happened to her? How can you test, not only what happened to her, but what she was like at baseline—when she was living with the dwarves? How do you know the apple put her into a deep sleep? Tell her story in appropriate detail, no exaggerations, and in the correct order of events.

The discussion/conclusion. Does Snow White have anything in common with Cinderella and Sleeping Beauty? Did anyone else have the same experience as Snow White? What is the evidence? Compare and contrast, showing strengths and weaknesses. What can be done better? What does the future hold? What is the lesson learned? How can others figure out how or why that red apple’s spell worked?

The audience. To whom do you wish to tell the story? In what journal do you want to “package” the story? How long a tale are you allowed to spin, how many strands of evidence (references) do you need to make your point; how many are you allowed to present?

The vehicle (journal). Some are of royal blood (New England Journal Medicine, JAMA, Nature, Science, Lancet, Anesthesiology), some are of a lesser station or notoriety. The poor will take your gifts more readily, but be wary of casting your pearls among swine. Do not underestimate the value of the novel cautionary tale that you have spun.

The cognomen (title). The title and the opening sentences should be powerful, if possible. Be clever. Editors need to be impressed enough to remember. Often a play of words or a twist of a phrase may be helpful.

The response to villains (the reviewers). Be courteous; do not respond flippantly in your rebuttal. Take the suggestions offered, as long as they do not conflict with your principles. Keep your dagger sheathed and your poison pen still. If you disagree with something they said/wrote, point it out politely and with evidence. Explain your changes clearly line by line, and make sure they can be understood. Answer the criticisms with respect. When you are given a deadline, do not miss it. Do not forget to address every point the reviewer makes. There is no magic required here.

To write or publish requires that you have a fire in your belly, soon to be followed by a thickening of your skin. Such efforts may start out on weekends, maybe at night, in between kids’ soccer games, or even during a jog. Writing has to be something you want to do, not something you have to do. Look at a clinical encounter (the action in your space of appearance) as a story that may be worthy of telling, an educational lesson to be passed on to others, and particularly in anesthesiology, one that encourages safety and vigilance. Live long, observe carefully, and write well.

References

1. Arendt, H. 1958. The Human Condition. Chicago: University of Chicago Press.

 


THOMAS PAPADIMOS, MD, MPH, is vice chair for academic affairs and director of critical care medicine in the department of anesthesiology at The Ohio State University Wexner Medical Center. He is also a retired Navy medical officer and has developed a keen interest in the philosophy of medicine, especially in regard to mentoring, aging, and the end of life. Helping young residents and faculty members get started in their scholarly efforts is a particular interest of his. His medical writings have spanned over 25 years and have resulted in over 150 publications and abstracts.

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