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Our learning is a combination of just in time and just in case. Most of us do both, but the emphasis definitely changes with our stage of our career, and the demands placed on us. As early learners we spend a lot of time thinking about just in case—we cram lots of extra knowledge into our heads. Many exams are based on this basic knowledge. As later learners we return to that knowledge—usually in a hurry, often as a refresher in need of a rapid update. As an example, I’ve never seen a child with epiglottitis—one of the many benefits of immunisation we’ve somehow failed to keep the wider public convinced about. I have spent a lot of time learning about it, and thinking about it. And in an emergency I think I’d know much of what to do. But I’d also want to think and look it up again and make sure that my knowledge was up to date.
It’s easy, then, to think that if I were to see a patient with epiglottitis, this would be interesting to write up. And certainly there may be important aspects like immunisation failure, overseas travel, and the fact that this is, in the UK, a notifiable disease which make this interesting. Reports about children you’ve seen can make excellent grand rounds, but I’d challenge you to think very carefully about what you are finding interesting. It’s rare that your clinical experience will be highly valued by me as a ‘Just in case’. I think that for the most part there are two aspects that come out of our clinical journeys. First, we are challenged to think: ‘How did I get to this diagnosis?’ And then this is linked to the second aspect, which is ‘What should I do next time, given a similar presentation?’ The important part about that second aspect is that, given the wonderful variety of our clinical lives, it is unlikely to be the same diagnosis the next time around.
Lisa Brown and Mark Tighe who edit the Epilogue section in the journal have a very good eye for this. Epilogue usually involves a final end diagnosis—but actually, that’s not the point. Even though it is very pleasing when you get it right. The point of good Epilogues are the differential, and the things you do to find the correct diagnosis and thus management. Our sister (parent) journal ADC has recently stopped taking any case reports—because rare complications of rare things aren’t a good use of our journal space. Note that this is not saying there’s no place for them—BMJ Case Reports is great. But, instead of a case report, why couldn’t your clinical experience become an Epilogue? They’re very popular, and each month we have a handful. We’ve a great little collection of them in this edition, with one of the more fun titles we’ve had in a while, for example, “My shoes are too small for me to fit in”, and just for fun, I’m making this paper this month’s Editor’s Choice (see page 250).
Other ways of recycling that case report into something that folk will find of generalisable interest are also in these pages. Our Fifteen Minute Consultations work best when they’re about clinical situations, although we’ve stretched a couple of those in this edition. We also have a section for what might be described as very long epilogues, or very long case reports, called Problem Solving in Clinical Practice. Most of these papers are about the journey—the clinical discovery—not the end diagnosis.
I wanted to introduce some of our newer section editors. I’ve already mentioned Lisa Brown who is hard at work in the Epilogue section. We also have Emma Dyer joining Philippa Prentice in the Guidelines section, and we have Rebecca Dalrymple and Amanda Friend joining Giordano Perez-Gaxiola—and behind the scenes Bob Phillips—in the Picket section. I’m looking forward to seeing some of their fizzing enthusiasm translated into changes in the journal. Look out for more changes in the next year, and as ever I love hearing from you so please do get in touch. If I’m a bit slow in replying it might be because I’m in the middle of a clinical journey or three, especially as winter descends in the Northern Hemisphere. Enjoy your own journeys…