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Editor's Choice

Interacting with theBMJ to solve clinical problems

BMJ 2003; 327 doi: (Published 16 October 2003) Cite this as: BMJ 2003;327:0-f
  1. Richard Smith, editor (rsmith{at}

    I sometimes compare medical publishing to a man standing on a corner with a megaphone shouting at passers by. It has not been a conversation. Editors give readers what they think will be good for them, and the process has been designed to benefit authors not readers. The authors need to get their work published in order to gain academic credit, promotion, and the next grant and often don't care whether anybody reads what they write. TheBMJ has tried to move away from this arid pattern, and our interactive case reports are one means of doing so.

    We started them as an experiment, but we regard them as a success and have plans to publish many more. Indeed, we welcome submissions. You need a team that includes a generalist, a specialist, possibly an expert on learning (although we can supply somebody), and certainly a patient. They must all be willing to respond quickly to what can be a flood of rapid responses.

    Any reader who hasn't noticed the cases might want to join the next round. We begin by describing the case in the paper edition of the journal, asking three questions, and inviting readers to respond through Questions about the diagnosis and further tests are usually well answered, but questions about “What would you say to the patient?” are, I judge, less well answered.

    The case that concludes today began with a description of Elisabeth, a 2 year old child who presented 17 days after a fever and rash with the skin falling off her fingers (p 916). Readers almost immediately suggested Kawasaki disease, which is rare, probably underdiagnosed, and for which there is no diagnostic test. We then have a second round of questions after giving further information. Four weeks after the case is first launched we publish commentaries from the authors on the case and the responses from their different perspectives. This case captures well the uncertainty of medicine. Pippa Oakeshott, a general practitioner, says that she thinks that few general practitioners in Britain would have considered Kawasaki disease. Yet Ed Piele–an educator–writes: “All doctors who look after children need to recognise the presentation of Kawasaki disease: the consequences of missing it are potentially disastrous…” But this is hard: a respondent pointed out that “in practice even cardinal symptoms have low predictive value if the incidence of the condition is very low.”

    The most interesting part of the case is often the view of the patient, which is usually very different from that of the doctors. In this case the parent is an anaesthetist, and she describes extremely well the problems of being both a doctor and an anxious parent. Please send us cases and join the interaction. The point is not to be clever but to learn, and I encourage readers to describe what they would say to patients when they have little idea of the diagnosis–a common circumstance.

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