Journal case reports can’t ‘explode myths’ — but they can encourage shoddy news stories

Take a guess where these headlines come from:

Parkinsonism can be cured

Therapeutic use of intermittent fasting for people with Type2 diabetes as an alternative to insulin

Although the language wouldn’t be out of place in a supermarket tabloid, these headlines are actually from The BMJ Case Reports journal; more specifically, from a collection labeled “Myths Exploded.” 

Bear in mind this journal has published over 15,000 case reports — what they dub “the single, largest repository of case reports in the world.”

So it’s worth asking: can myths in medicine be “exploded” by case reports? And what does that even mean?

Furthermore, is it responsible to suggest such anecdotes actually debunk myths, and then turn around and promote that erroneous notion to a much bigger audience via news releases?

The response from BMJ Case Reports

Dr. Seema Biswas

“The ‘Myths Exploded’ category was originally intended for authors rather than readers,” says Dr. Seema Biswas, Editor-in-Chief of BMJ Case Reports. “ It was to encourage reporting cases that may challenge conventional approaches and stimulate further research.” She added:

“Case reports are ideal for providing unique clinical details, but they shouldn’t be regarded as evidence for changing clinical practice. So I do take your point. Considering the expanding search and uptake of available information by the broader public not accustomed to levels of evidence of clinical data, I accept that this label [‘Myths Exploded’] may be counter-productive and we will be reviewing the use of this category by the end of the year.”

Let’s be clear: We’re not disparaging the value of case reports. Biswas is right to point out they can inspire and guide new hypotheses and avenues of research.

But the headlines above are based on cases of 1 and 3 subjects, respectively. They do not have the statistical power to debunk (or prove) myths. But when they are promoted by a major publisher with a global circulation, they do have the power to propagate myths.

Cures and reversals based on single cases?

Although not recent (originally published in 2013), the first case about “Parkinsonism” is a good example of “the words matter.” The 67-year-old subject of the study most likely had Parkinson’s-like symptoms from a “vasculitis/vasculopathy affecting [her] basal ganglia” (ie. inflammation of the blood vessels supplying the part of the brain associated with Parkinson’s disease). So in one sense, the headline is partially correct: the treatment she got (for another disease), improved her Parkinsonian-like symptoms (aka “Parkinsonism”).

But can readers be expected to differentiate a “cure” for Parkinsonism from a cure for what most people know as “Parkinson’s Disease”? 

What is the myth here? Is it that Parkinson’s disease can’t be cured? That isn’t a myth. It can NOT be cured. This woman most likely didn’t have Parkinson’s disease. Her Parkinsonism was caused by something else, and that’s what went into remission. Why even dangle the word cure if it could be misconstrued?

Fortunately, from what we could see, this “Myth Exploded” report did not result in misleading news coverage.

But that’s not the case with the second study of 3 men with diabetes who went off their insulin after 10 months of intermittent fasting. We wrote about that last week.

The case report, promoted to journalists and the public by this news release, led to erroneous news coverage strongly suggesting that fasting could reverse type 2 diabetes. The emphasis was clear: reversal. But this case report cannot prove reversal. Likewise it can’t prove or refute that fasting is a safe, sustainable, or effective treatment for Type 2 diabetes. Nor can it debunk any myths … which are what?  That diabetes can’t be reversed? That fasting can be therapeutic? Again, it’s unclear what myth got “exploded.”

Case reports as entertainment?

From The Telegraph’s ‘Don’t Hold in a Sneeze’

There’s a broader issue here that goes beyond the “exploding myths” case reports and applies to case reports in general. That is, as Biswas points out, the fact that more people are searching for (and finding) case reports who may or may not know they’re more anecdotal than they are vetted scientific evidence.

What should we expect the general public to do with news releases like these from BMJ Case Reports?

Dental brace wire found in woman’s bowel after 10 years

Cold open water plunge offers instant pain relief

Man develops severe ‘thunderclap’ headaches after eating world’s hottest chilli pepper

Don’t hold your nose and close your mouth when you sneeze, doctors warn

If case reports ≠ evidence for changing medical practice, then what’s the goal here? Entertainment? If so, it’s not harmless entertainment because news organizations latch on to these quirky anecdotes and pass them along to the public as some bizarre mix of medical curios and medical advice. Consider these news stories based on the releases above (presented in the same order):

• The New York Post opted to scare people that swallowing objects could lead to twisted intestines (volvulus).
• Time wrote: “given the impressive results seen in the case study, cold-water swimming may be worthy of further study for pain.”
• Does NBC News think we should avoid peppers because “the pepper-eater wasn’t suffering from a stroke, but a major artery in his brain had narrowed.”
• Here’s the headline from The Telegraph: ‘Don’t hold in a sneeze, warn doctors. It could be the death of you.”

All these headlines were generated by the cases reports of one individual. And all these cases reports were promoted via news releases to journalists and the general public. They potentially reached thousands or millions of people.

Who benefits from this?

At issue here is something quite important. If the primary benefit of case reports is that they highlight issues that may lead to further research, then their primary audience should be researchers.

Because they are purely anecdotal, and do not represent strong scientific evidence, they should not be disseminated to a “broader public not accustomed to levels of evidence of clinical data” unless it’s made crystal clear:

Case reports do not equal evidence that should be acted upon. They’re simply anecdotes. For these two reasons, people should not base health decisions on them.