- This is not a critique of a research based practice, this post is more congruent with a quest of a provider (me. … you?) to find the best practice patterns, solutions and outcomes.
A systematic review in research is like a cluster of polls of people. Take 100 people and poll them about politics and then make an assumption about how the US thinks about an issue. When performing research we take a sample of people, treat them and poll the results, if you will. Then we make assumptions based on the rigor of the treatment or poll as it applies to the general (or specific) population.
What was the last political poll that defined your city. Do you think it was a good representation? Ok, maybe it was, but what about your neighborhood? Do 60% of people agree with position X? How about your family? How about you, the individual? Does 60% of yourself agree? Maybe, but probably not. The closer you get to the individual (and we treat individuals) the less accurately research applies. (As we know, the more internal validity a study has; the less external validity it has. We are stuck aren’t we!)
So there is much talk of the case report being low level, or simply being a “starting point” to further research. While true in many ways, there is still much to be learned about how an individual reacted to a treatment or course of action. In much the same way we can learn a lot about life from an individual’s life journey, we can learn a lot about treating from case reports. You can learn just as much by reading a book about Leonardo da Vinci, as you can a book about Tuscany.
Of the three pillars, all carry bias with them. The clinician’s experience can be skewed, the patient is biased by media and life experience, and research is bias as well, including publication bias, not searching for a null-hypothesis, etc. The case report is the closest to the fire, to the action, and most likely to get burnt by bias. It screams of the fingerprints of the clinician, the patient and the methods. But so does your day and your treatment session! Check out the InTouchPT blog post about some of this here.
Treatment research may just be the most rigorous thing we can do to eliminate bias. But we don’t eliminate individualism. And patient’s bring individualism to the table. Every time.
So don’t discount that case report, you just might learn something!