Somehow, people have come to believe that generalized, reproducible knowledge is the truth; that evidence-based medicine is the solution to our troubles.
Evidence-based thought, however, is used to prove what we believe to be true. This rant about how we build knowledge will segue a more moderate introduction to the case as a method of knowledge production.
No scientific report is value free; it is shaped by the mind of the researcher. Their worldview, a product of the culture in which they live, influences choice about what receives their "scientific gaze." Subjective reasoning then determines how data is to be processed and subsequently presented. This ultimately subjective stance from which objective data is created forms the bedrock of evidence-based medicine (EBM), from a reduced, objectified, randomized controlled trial to practice-based research. Thus, the scientific endeavor lives within and is created by the researcher as subject. But that is not how research is presented!
Often, practitioners of scientific method adopt a third-person voice in their writing in an attempt to project an "objective" stance, whereby general population-based knowledge sustains primacy over specific and local knowledge. Philosopher of science Edgar Morin considers that, "The greatest progress in contemporary science has been affected by the reintegration of the observer into the observation." This introduction was built from a qualitative research method called critical theory, which explores power dynamics and culture.
This brings us to the literary form of the case: a local, personal record of expert knowledge. Not to be dismissed as anecdote, the case achieves a level of reliability through a series of rigors to be detailed here. Before moving on to historical knowledge about the case in Chinese medicine, the editors of the journal Global Advances in Health and Medicine have provided, under "For Authors," a template that can be downloaded for case presentation. This template has been vetted across various portions of the healthcare community and can serve as a starting point for case reporting in all master and doctoral programs within the field.
In this mini-series, I use an introduction I wrote for People's Medical Publishing House on the case. They are involved in publishing a whole series of case-based texts for purposes of delivering expert knowledge. Here, I explore historical, contextual, theoretical and practical aspects of the Chinese medical case. From here on in, the focus is upon the qualitative research method of the case. As a single example emphasizing specific, practical and local knowledge over generalized theory, the case has significance beyond exploration for scientific research. Education and transmission of expert knowledge remain at the heart of the matter.
Experts write cases to show efficacy and claim validity for a judgment. Embodying the expertise and experience of authority, the case captures context-dependent knowledge of senior practitioners. It provides a vehicle for cataloging and communicating expert observation and action. Thus, the reader may be empowered to cultivate expertise that encompasses complexity, rather than formulaic, rule-based thought.
History of the Case Study in China
Chinese case studies were shaped by classical literature beginning with the earliest works, extending through the 20th century. The rhetoric and polemics used for law and governance of state often provided models for these early authors. For example, Si-ma Qian published some of the earliest known medical cases in Records of the Grand Historian (145-87 BCE). In it, he presented 25 consultation records of Chun-yü Yi, who used them to gain acquittal during an imperial interrogation into his medical practices.1
Over time, the case record evolved functions other than management of medical-legal risk. Song Dynasty (960 CE -1279 CE) physician Qian Yi built his reputation with pediatric case records, which placed him in the annals of Chinese medicine.
During the Ming Dynasty (1368-1644 CE), the growth of pediatrics as a medical specialty provided a context for the flourishing of case records as tools for building knowledge. Sinologist Judith Zeitlan suggests that the influential 16th century physician, Sun Yikui, may have used cases to convince the public that he was not a reckless physician.2 The importance was not so much the credibility and accuracy of a case, but whether the physician has followed the appropriate course of action in a specific situation.
Medical-legal risk, reputation and market position were not the only motives for writing cases. By the early Qing Dynasty (1644- 1912 CE) scholars were involved in collecting, editing and publishing case studies, as well as providing commentaries. Altruism became a motivating factor in the development of the case in Chinese medicine.
The development of medical case studies in China was part of a progression toward more public forms of knowledge. Writers sought to demonstrate efficacy and establish validity for a particular method or theory.2 This form of knowledge building creates what Robert Stake calls "an instrumental case study where the case is used to draw insight from an issue or to set forth a generalization."3
Defining the Chinese Medical Case
As a literary genre, Charlotte Furth defines a case as, "expansive notion ... that any 'instance' can be carved out of the flow of events set in time and space and be set aside to be made particular."2 The details of a story are enhanced and built by points of interest in order to serve the claims of the expert.
The case as a culturally embedded object has had differing forms when the past is compared with the present and the West with the East. Rather than a detailed record of signs and symptoms, imaging and lab studies of Western practice, the Chinese medical case study presents clinical rationale, pattern differentiations and the progress of treatment. It is used to highlight best practices through a detailed analyses of the expert's actions.4
This series will continue the focus upon the case as a tool for knowledge building. As a local form of knowledge, it is my opinion that the well-done case study has an equal stature to the randomized controlled trial, but for different reasons, such as transmission of local, specialized knowledge and the imprint of the significant game-changing case as discussed in Black Swan Theory whereby we consider all swans to be white ... until we see a black one. In that instance, the single outlying case changes the nature of belief about reality.
Zeitlin JT. The Literary Fashioning of Medical Authority: A Study of Sun Yikui's Case Histories. In: Furth C, Zeitlin JT, Hsiung P, editors. Thinking With Cases: Specialist Knowledge in Chinese Cultural History. Honolulu, HI: University of Hawaii Press; 2007.
Furth C. Introduction: Thinking With Cases. In: Charlotte Furth JTZ, Pingchen Hsiung, editor. Thinking With Cases: Specialist Knowledge in Chinese Cultural History. Honolulu, HI: University of Hawaii Press; 2007.
Stake R. Qualitative Case Studies. In: Denzin N, Lincoln Y, editors. The SAGE Handbook of Qualitative Research. 3rd Edition. Thousand Oaks, CA: Sage Publications; 2005.
Morris W, Li S-q. Li Shi Zhen's Pulse Studies - An Illustrated Guide. Mandot M, editor. Beijing: People's Medical Publishing House; 2010.
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