Abstract
Dr. von Gunten initiated the series in volume 3. 1 The goal was to try to reproduce, in a journal format, the kind of discussion that happens during a case conference where junior and senior colleagues are gathered to amplify the teaching points of a real case on the service. At best, the reader will feel like he or she is listening to an erudite discussion at a large academic program.
In the beginning, there were only four issues each year. When Charles took the role of Editor-in-Chief with volume 8, James Hallenbeck, M.D., Associate Professor of Medicine at Stanford University and Director of the Hospice and Palliative Care Program at the VA Palo Alto Health Care System took up editing the series. Jim was chosen because of his reputation as an outstanding clinician–educator as well as scholar in the field. The number of issues increased to six per year. In retrospect, that seems wonderfully slow paced. During those early years, as often as not, he solicited write-ups of cases he thought would be interesting or “something different.” That has gradually changed over time. While he occasionally suggests a possible case, the number of case discussions that are submitted to the journal has increased dramatically—more than keeping pace with the increase to 12 issues each year. The increase has challenged him to sustain the original intent of the series.
In our view, a case discussion should be “practical”; it should present “news clinicians can use.” The publication of cases satirically called “fascinomas” or “zebras” is best done in a letter to the editor. Since we publish a case discussion series in the field of hospice and palliative care, the case discussions should test the boundaries of what a “case” really is and explore the utility of cases in a journal and in teaching. Consequently, a case discussion of which we are particularly proud is the submission of Dr. Janet Abrahm and the program at the Dana-Farber Cancer Institute in Boston, Massachusetts, which really revolved around the creation of a facility policy for palliative sedation. 2
The thrust of this series contrasts with standard medical training. Many clinicians think far too narrowly and shallowly about cases. From a palliative care perspective, narrow means excessive focus on the individual patient and the medical pathophysiology of that patient. Very commonly, submitted manuscripts will spend as much as 80% of the write-up outlining all the tests, lab values, etc., a patient had. Presumably, this reflects the context in which they practice or their sense this is expected of a “good” case discussion because they have observed them in their medical centers. Yet, these details often contribute remarkably little to the key point of the case. Shallow means that, even when the focus is a practical one, too often the discussion seems superficial without much of an “ah-ha” factor that mirrors the course of the clinician trying to “solve” the case.
The case discussion series also serves as an entry point for journal writing—for junior clinicians and increasingly for authors who are trying to reach out beyond their own country (and often language). In this regard we think we have been modestly successful. The price, however, has been that we increasingly draw submissions of marginal technical quality (and often suffering from the narrow/shallow problem). The challenge is to identify which manuscripts represent “diamonds in the rough” and to put in the time and effort to work with the author(s). If the underlying case is really good, we sometimes go well beyond “reviewing” submissions to extensive editing (sometimes, almost rewriting) manuscripts.
Therefore, it is time to pass the series on to yet another generation. At the recommendation of the senior associate editors, Dr. Craig Blinderman and Dr. Eva Chittenden have agreed to take over the series from Dr. Hallenbeck. One of the great professional rewards of medicine is to enjoy the generativity of watching the next generation “come along.” We trust they will bring new enthusiasm to the series, and continue to mentor new talent from around the world. In addition, Dr. von Gunten advocates that Dr. Hallenbeck gloat that the Journal of Palliative Medicine needed to recruit two people to do the work that he has done while walking to work uphill both ways in waist-high snow.