10 minute consultations

The articles in this occasional series aim to advise general practitioners on the best way to use the first consultation for a common clinical problem. There is no need to cover what should be done in a subsequent consultation or in the long term: the whole point is to cover what can be said and done in 10 minutes.

These articles should be evidence based and should, when appropriate, refer readers to valid and well written patient information. Articles should be no longer than 600 words, with one box, figure, or table plus a box of three or four suggestions for further reading. These articles do not have a formal list of references. The main text should have three sections:

• a short case history (if this is about a real patient we will need their consent to publication)
• What you should cover
• What you should do 

Interactive case reports are presented in three parts, published in the BMJ over five weeks with open debate from readers on the web through rapid responses on bmj.com

We ask several people, including clinical and educational experts and the patient, to comment on the case. We also invite them to moderate and stimulate the web debate as the story unfolds.

Here is our detailed guidance on producing an interactive case report for the BMJ:

• The case should describe a real patient who presented initially in primary care or the accident and emergency medicine department
• The case should have subsequently involved secondary care specialists in mainstream departments such as obstetrics, gastroenterology, haematology
• The case should be sufficiently complex to raise interesting clinical, investigative, diagnostic, and management issues but not so rarefied that it is only likely to appeal to a minority of BMJ readers. Cases which stimulate debate, air uncertainties and controversies in management, and raise ethical questions, are particularly welcome
• Please include brief details of the social circumstances of the patient with some indication of the (possible) impact of their illness on them and their family. This information is as important as the medical information, because it will help commentators to remember the patient’s perspective of illness. We hope that patients will be willing to use their real first names and will not mind that they are potentially identifiable. Of course, patients can opt for anonymity if they wish, in which case the personal information in the report will have to be quite limited
• Please provide 3-4 clinical illustrations so that there is a at least one illustration for each of the three parts of the case report (such as radiographs, CT scans, ultrasound scans, ECGs – preferably relating to this patient, though library illustrations will do). Other material such as boxes, figures and tables are welcome but may have to be published only on bmj.com if there isn’t enough space in the print BMJ. This material may help to generate further questions for readers. We do not need references for any part of your case report
• The case report should conclude with a clear outcome that we can publish 4-5 weeks after the initial case history and questions. This would usually be the definitive diagnosis (but not inevitably: it may be a presumptive one) and some clear management endpoint
• Please note that the patient needs to be involved closely in this interactive learning. You will have to obtain the patient’s written and informed consent to publication using the BMJ consent form.
• Please also invite the patient to comment on his or her own case and on the experience of seeing the debate unfold in the rapid responses on bmj.com. Our advice to patients is copied below. This involvement means that the patient will have to have access to email and the web and to feel reasonably confident in using them. If he or she does not want to or is unable to do this, please explain that we would invite a patient advocate to comment on their case instead
• Please provide for each of the first two parts of the case report a list of key questions/topics/management issues that the case raises. These questions should be written in plain language such as “if you were the doctor managing this case, what diagnoses would you consider?”…”what tests would you order?”…”is there anything else you would ask the patient?”… “what would you say to the patient at this time? The questions should prompt rapid responses to the case on bmj.com as well as giving a focus to the invited commentators 
• The case presentation should comprise approximately 1100 words with at least 3 illustrations overall. It should be structured in three parts for publication over five weeks:
• Initial presentation. For publication on its own in the first week. Please describe here any first line investigations or immediate management. The text should be approximately 350 words with one or more illustration(s) and 3 or 4 questions. Readers and invited commentators would be urged to debate the case in rapid responses on bmj.com in the week after publication
• Case progression. For publication in week 2, one week after the first part of the case report. Again, this should be approximately 350 words with one or more illustrations and questions as above, and rapid responses would be invited. Please say here what happened next to the patient’s clinical condition and mention any treatments, further tests and referrals to specialists
• Case outcome. For publication in week 5. This should comprise up to 400 words with one or more illustrations, covering the management and outcome of the case. This part would be accompanied by several invited commentaries – at least by one or more clinical specialists, a GP/family practitioner, the patient or a patient advocate and, when appropriate, an education expert. Each of these commentaries would discuss the case (with references as appropriate) and would also mention how the open debate developed on bmj.com

Evidence based case reports 

These reports show how evidence can be applied at all stages of patient care, and describe a clinical dilemma raised by a real patient. We will need the patient’s written and informed consent to publication using the BMJ consent form.

These articles should not exceed 1200 words. Please define the clinical question in four parts; patient, intervention, comparison, and outcome. The report should show that you have searched for, cited, and summarised studies of appropriate relevance, design, and quality, and should state which bibliographic databases you have used. 

Finally, the report should answer the research question or state that there is no answer available. 

Lessons of the week

These are usually case reports or case series alerting readers to potential clinical problems. They should be less than 1200 words long and accompanied by a single sentence of up to 15 words stating the lesson. You will have to obtain all patients' written and informed consent to publication using the BMJ consent form. We welcome illustrations.

The lesson should be as specific as possible and aimed at general readers. The BMJ's editors and peer reviewers use the following questions to assess lessons of the week: 

• How common is the condition? (It should not be so rare that it is irrelevant to most BMJ readers). 
• How commonly is the condition missed? 
• How serious is it if missed? 
• Will this report contribute to preventing missed cases? 

Patient’s journeys

From time to time we publish articles called “A patient’s journey” written by patients. The purpose of these articles is to help our readers (mostly general practitioners and non-specialist hospital doctors from all over the world) understand how it feels to face a difficult diagnosis and to live with the condition—the effect it has on the quality of life of patients and carers and their relationships with others.

The main text of the article should be less than 2000 words and, unlike most BMJ articles, have no formal references. We also need one box identifying resources such as patient support groups, books, leaflets, and websites. (Web addresses (URLs) should be listed and it would be helpful if you could describe each website in a sentence or two and also say if a password is needed to access it.)  Other boxes might include one highlighting any general lessons you have learned about coping with the condition, a box listing say the things you did not tell your doctor—for whatever reason, or a box describing the condition and its natural course (see below). Photographs and other illustrations are welcomed.

Because these articles describe a journey, we suggest you try and answer the following questions in the article. 

• What is the natural/typical course of the disease? (This may be written by a doctor and should be placed in a separate box—see below)
• What is the good and bad news? What's wrong? What's going to happen? How is it going to progress or get better?
• How much do you have to travel alone? What was it like losing independence and dealing with changing relationships and social roles?
• Who are your companions on the journey?—friends and family, professionals, support organisations). What are your ways of coping?
• What did you need along the way?—information, help, and treatment. What has really made a difference?
• Did you lose the path along the way? What problems arose over time? What have been the most taxing, stressful, and difficult parts of the journey?
• Where are you on the journey today? What has happened to date? What are your hopes and fears for the future? What have you learnt from your journey?

The BMJ is read worldwide. Therefore the article should focus on day to day problems faced by the individual rather than on issues arising directly from local healthcare services and be written in a style suitable for international readers.

Contributions from doctors and health professionals: We think it very unlikely that doctors or journalists can act as proxies for patients in describing a patient’s journey accurately as the patient would. The value of “A patient’s journey” is that it is written from the personal experience of one or more people with the condition perhaps with a contribution by a carer.

The article, however, needs to be scientifically accurate wherever medical information is provided. We may sometimes commission a doctor to contribute a separate section for the article about the nature and typical course of the condition and its usual treatment. The patient’s own doctor or healthcare provider may also be able to contribute by describing his or her reactions to the individual patient’s illness and the relationship with the patient and carer. Any contribution from a doctor needs to be separate from the main text, clearly identified, and preferably in a box.

When submitting the article please provide a title page, giving the names, addresses, and email addresses of all authors. For any patient who is not an author but is mentioned or quoted in the article or appears in a photograph, please send us their signed consent to publication, using the BMJ consent form.

Patients may remain anonymous if they prefer in the published article, but we would need to know their full name, age, and address. When names are declared we use full names (given and family names) and ages in the article. We do not use partial or fictitious names.

Quality improvement reports

We are keen to publish interesting and important descriptive reports on how people try to change and improve health services. Such reports do not fit easily into the standard IMRaD format for research papers.

Quality improvement reports should not exceed 2000-2500 words and 24 references and

• brief description of context: relevant details of staff and function of department, team, unit, patient group
• outline of problem: what were you trying to accomplish?
• key measures for improvement: what would constitute improvement in the view of patients?
• process of gathering information: methods used to assess problems
• analysis and interpretation: how did this information help your understanding of the problem?
• strategy for change: what actual changes were made, how were they implemented, and who was involved in the change process?
• effects of change: did this lead to improvement for patients – how did you know?
• next steps: what have you learnt/achieved and how will you take this forward?

Quality improvement reports have structured abstracts with these subheadings: problem, design, setting, key measures for improvement, strategies for change, effects of change, lessons learnt.

Drug points

These usually report new adverse drug reactions or drug interactions. Priority will be given to drug points that report more than one case; those in which the patient is rechallenged with the drug; and those which exclude other possible causative factors (disease process, other drugs, environmental agents).  Please ensure that your drug point follows our checklist:

• please ensure that the main text is no longer than 300 words with no more than 5 references
• as with any report of adverse drug reactions, your drug point should include the following information (Ciba-Geigy Workshop  BMJ 1984;289:898):
  •  the age and sex of all patients described
  • the suspected drug, and all drugs currently being taken, with start dates, stop dates, restart dates, and outcome (generally something more than simple coincidence in time is required: e.g. re-challenge, with the patient’s informed consent, or immunological investigations may tip the balance of probabilities)
  • details of the patient’s prior experience with this drug and of any adverse reactions to related drugs
  • details of other diseases and/or environmental factors, and their timing
  • ancillary information from the pharmaceutical company and regulatory agency
  • references to relevant published reports
  • other factors relevant to verify specific types of adverse drug reactions (e.g. blood concentration in overdose, baseline laboratory data, ethnic group)
• there should be no more than four authors
• please do not use proprietary drug names
• we welcome relevant clinical photographs
• we expect you to contact the UK Committee on Safety of Medicines (or the equivalent committee in your country) and the manufacturer of the drug to enquire if they have had similar reports.  You must include their responses within the text of the drug point
• We do need to see the signed consent to publication of all patients described in the drug point, using the BMJ consent form, unless the patient is dead, and we decide that that publication without consent has sufficient benefits to public health.

Change page

This occasional series aims to alert clinicians to the immediate need for a change in practice to make it consistent with current evidence. Our criteria for each proposed change are that:

• it targets a single therapeutic or diagnostic intervention for a reasonably common clinical problem
• it is underpinned by compelling and robust evidence
• it is both feasible and beneficial.

The main text should have four sections with these subheadings:

• the clinical problem
• the evidence for change (should include a box of literature search and selection methods, and indicate the strength of the evidence when citing each study eg “randomised controlled trial/case series of 121 patients”)
• barriers to change
• how should we change our practice?

 These articles should comprise no more than 800 words of main text with up to 10 references and a box of up top five key single sentence bullet points summarising the proposal for change.

We welcome contributions for this series. If you would like to propose a change in clinical practice please email your proposal, briefly indicating how it fits the above criteria, to changepage@bmj.com.

Rational imaging

This occasional series updates clinicians on the best use of different imaging methods for common or important clinical presentations whose management will be influenced by ordering the right imaging test.

The main text should have three sections with these subheadings:

• the patient
• what is the next investigation? (List a few possible imaging methods, and the limitations and benefits of each)
• outcome (what happened to the patient as a result of imaging)

These articles should comprise no more than 800 words of main text with up to 5 references, high-resolution images, and a box of up to four learning points (single sentence bullet points summing up the main lessons from the article). As these articles are based on real cases, we will need each patient’s consent to publication in the BMJ.