Mark Gabbay’s question arises so often that I think we should perhaps
readdress it as case histories and their significance, power, validation,
place in the hierarchy of research and their extrapolatability (if I may
use such a word) where discussed on this list about 18 months ago.
This is also covered in some new textbooks which other members will be
able to give to Mark.
My interest is a parallel one of using small numbers in research (not the N
of 1 thing) which has also be discussed in this forum before.
Several years ago I completed a doctorate in family medicine\general
practice. My thesis was that a few patients were coming in to see me who
we as doctors were packaging in to boxes such as anxiety neurosis,
depression, personality disorder, somatisation disorder etc etc. I felt
they were unhappy so we researched the phenomenon of Unhappiness (ref.Can
Fam Physician 1996:42:645-651).
Only 4 patients in my practice fitted our selection criteria reasonably
uniformly. The only appropriate research methodology to investigate this
condition was the purely qualitative method of existential phenomenology.
My promoters who included a professor of research psychology and a senior
research philosopher spent over 200 hours over 3 years discussing and
teaching me the method.
Whilst we were doing the verification\validation\trustworthiness via the
standard qualitative processes we were continually questioned by those we
submitted it to for triangulation\explosion\free imaginative variation etc
with the question, How can you do research with only 4 patients? (And what
the dickens is existential phenomenology?).
Which brings me, rather long windedly, to my point about small numbers in
medical research and case histories (or clinical biographies or patient
stories or several other similar texts that are used as research
information).
Parkinson described only 6 cases of his eponymous disease from his practice
in Shoreditch in London in his original description (Parkinson J. An Essay
on the Shaking Palsy. Sherwood, Neely and Jones, 1817).
The Argyll Robertson Pupil was described initially in one case (Argyll
Robertson D. On an interesting series of eye symptoms in a case of spinal
disease. Edinburgh Medical Journal 1869; 14:696-708).
(By the way if anyone else has examples of similar small series from
practice could they let me know, as I am building up my case)
And this brings me to my real and final point (at last) which is that I am
keen on trying to keep general practice research within my practice. As
soon as I leave it and go into the general practice unit at the medical
school I seem to have the living reality of myself and my practice removed.
My patient’s relatives, the receptionist’s background whispered
information, my partner’s comments in the tea room (the so called rich or
thick texts) are removed and I am told I must have a trillion cases and
something called statistical significance (I am numerically challenged).
I am trying to write a post doctoral monograph which I have tentatively
called :
In Search of an Intrinsic General Practice Research Methodology.
Could anyone help me with advice? This may have already been covered
before.
Yours
Dr Chris Ellis
29 Oriel Road, Pietermaritzburg, KwaZulu\Natal, South Africa.
Fax 033-3868400. Tel : 033-3869208. E mail : [log in to unmask]
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