Cases are built within boundaries. Such bounds may be a program, event, activity or individuals. In this instance, a medical case has boundaries that include clinical interactions that are comprised of history, signs, symptoms, diagnoses, treatment plans and treatments.
There are two types of case: intrinsic and extrinsic. The intrinsic case study conveys knowledge of a single event. Its value is limited to a unique experience. Thus, intrinsic cases can be most easily dismissed as "anecdotal." Extrinsic case studies might be focused upon cultural considerations for the patient, family and friends, providing for transferability and knowledge into other contexts.1
As a matter of distinction, the Western medical case study tends to focus upon history, disease process, and therapeutics, whereas Chinese medical case tends to explore the thought and strategies of the physician related to the patient. Each style provides truth claims specific to a particular situation. The case achieves primacy in the creation of transferable knowledge through exemplars of expertise and expressions of critical thought.2-4
Case Study: Purpose and Method
Cases are often presented in collections or series, which are connected with each other through shared patterns that are further elucidated by distinguishing differences and commonalities.5 Such distinctions are used to carve subjective experiences into literary form.2
Thus, the medical case is distinguished from tales and lore by the use of different grammatical voices such as third person — which creates distance and a sense of objectivity and first person, which emphasizes personal authority. The relevancy of the case is also shaped by the tone of its verbs, for example: consider, weigh, judge, analyze and determine.6
The case as a process may involve several forms of reasoning. Science historian John Forrester recommends three case approaches:7
Classify cases according to areas of specialization such as pain, dermatology or women's health.
Organize in terms of thought models such as Shang Han Lun theory.
Organize the case along the lines of a particular lineage or a famous practitioner's work.
The Chinese medical case is one in which such deliberations are expected to have a clear conclusion. As an example, the Chinese case tends to focus upon the clinical outcomes. If the case improved in part, the practitioner will describe why and how, and then provide the next course of treatment. The narrative is often situated at the intersection of medical canon and practice. The physician may explain the useful departure from canon, or the effective application thereof.
Both qualitative and quantitative data are used in case presentations. The physician's case records often contain quantitative data such as blood pressure, lab levels and pulse data such as rate. Consistent with the method of phenomenological research, brackets may be used to demarcate the physician's thought.
Chinese medical cases are usually presented in collections rather than as single entities. It is useful to analyze them collectively in order to derive the shared relations while sustaining the individual character of each demarcated set of observations.
Science and the Case
The current emphasis upon quantitative evidence as the arbiter of truth in science is already questioned in the halls of academe.8-11 Consider John Forrester's thoughts, "There is not one method in science, established for all time, the eternal benchmark and guarantor of truth. There have been different methods, discovered and employed in different times and places."7 Qualitative researcher, Flyvbjerg, identifies and corrects five prevalent misunderstandings about case study research:12
General, theoretical knowledge is more valuable than concrete, practical knowledge.
One cannot generalize on the basis of an individual case and, therefore, the case study cannot contribute to scientific development.
The case study is most useful for generating hypotheses, whereas other methods are more suitable for hypotheses testing and theory building.
The case study contains a bias toward verification, i.e., a tendency to confirm the researcher's preconceived notions.
It is often difficult to summarize and develop general propositions and theories on the basis of specific case studies.
Most current forms of reasoning are rooted in the teachings of Aristotle, where science and reality can be represented quantitatively, hierarchically and in order of generality. The Darwinian concept of evolution broke with this Aristotelian view by focusing upon populations of individuals, which vary along an indefinite number of axes.12 Philosopher of science, Karl Popper, took exception with generalization, providing this example: the single observation of a black swan falsifies the proposition that "all swans are white."13 Here the case gains primacy in the Evidence Based medicine pyramid scheme.
The practice of case research brings information about the social and historical context in which an expert practices. The time period and social context inform the observer about the nature of reasoning and the details of the case inform the reader about the situation of the case historically and socially. The case can be used to convey styles of reasoning as well as details about specific actions. These data can often be as informative as the details of the signs and symptoms.
Local knowledge, as received through the case, works well for teaching and learning in comparison to general knowledge, which derives from randomized controlled trials serving as a model for evidence-based practice. There are exceptions where cases do serve the needs of general knowledge; they are the archetypal cases where significance and key distinctions extend to influencing the body of general knowledge.
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Stake R. The Art of Case Study Research. Thousand Oaks, CA: Sage Publications; 1995.
Stake R. Qualitative Case Studies. In: Denzin N, Lincoln Y, eds. The SAGE Handbook of Qualitative Research. 3 ed. Thousand Oaks, CA: Sage Publications; 2005.
Stake R. Multiple Case Study Analysis. New York, NY: Guilford Press; 2006.
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Forrester J. If P, then What? Thinking in Cases. History of the Human Sciences. August 1, 1996 1996;9(3):1-25.
Reason P. Three Approaches to Participative Inquiry. In: Denzin N, Lincoln Y, eds. Strategies of Qualitative Inquiry. Thousand Oaks, CA: Sage Publications; 1998.
Kincheloe JL, McLaren P. Rethinking Critical Theory and Qualitative Research. In: Denzin NK, Lincoln YS, eds. The SAGE Handbook of Qualitative Research. 3 ed. Thousand Oaks, CA: Sage Publications; 2005.
Denzin NK. Interpretive Ethnography for the Next Century. Journal of Contemporary Ethnography. October 1, 1999 1999;28(5):510-519.
Ceruti M. Evolution Without Foundations. Cresskill, NJ: Hampton Press, Inc; 2008.
Popper K. The Logic of Scientific Discovery. London: Hutchinson; 1959.
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