Hickam’s dictum, Occam’s razor, and Crabtree’s bludgeon: a case of renal failure and a clavicular mass
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Simone Blaser
Abstract
Objectives
Our discussant’s thoughtful consideration of the patient’s case allows for review of three maxims of medicine: Occam’s razor (the simplest diagnosis is the most likely to be correct), Hickam’s dictum (multiple disease entities are more likely than one), and Crabtree’s bludgeon (the tendency to make data fit to an explanation we hold dear).
Case presentation
A 66-year-old woman with a history of hypertension presented to our hospital one day after arrival to the United States from Guinea with chronic daily vomiting, unintentional weight loss and progressive shoulder pain. Her labs are notable for renal failure, nephrotic range proteinuria and normocytic anemia while her shoulder X-ray shows osseous resorption in the lateral right clavicle. Multiple myeloma became the team’s working diagnosis; however, a subsequent shoulder biopsy was consistent with follicular thyroid carcinoma. Imaging suggested the patient’s renal failure was more likely a result of a chronic, unrelated process.
Conclusions
It is tempting to bludgeon diagnostic possibilities into Occam’s razor. Presumption that a patient’s signs and symptoms are connected by one disease process often puts us at a cognitive advantage. However, atypical presentations, multiple disease processes, and unique populations often lend themselves more to Hickam’s dictum than to Occam’s razor. Diagnostic aids include performing a metacognitive checklist, engaging analytic thinking, and acknowledging the imperfections of these axioms.
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Research funding: None declared.
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Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
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Competing interests: Authors state no conflict of interest.
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Informed consent: Informed consent was obtained from all individuals included in this study.
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Ethical approval: The local Institutional Review Board deemed the study exempt from review.
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- Letters to the Editor
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Articles in the same Issue
- Frontmatter
- Editorial
- From Camille Nούς to Apollonian and the Dionysian scientists
- Review
- The role of D-dimer in periprosthetic joint infection: a systematic review and meta-analysis
- Mini Reviews
- Updated picture of SARS-CoV-2 variants and mutations
- Systematic review and cumulative meta-analysis of the diagnostic accuracy of glial fibrillary acidic protein vs. S100 calcium binding protein B as blood biomarkers in observational studies of patients with mild or moderate acute traumatic brain injury
- Opinion Papers
- The 6C model for accurately capturing the patient’s medical history
- Webside manner: maskless communication
- Original Articles
- Ways that nurse practitioner students self-explain during diagnostic reasoning
- Diagnostic reasoning: relationships among expertise, accuracy, and ways that nurse practitioner students self-explain
- Perspectives on the current state of pre-clerkship clinical reasoning instruction in United States medical schools: a survey of clinical skills course directors
- Use of a structured approach and virtual simulation practice to improve diagnostic reasoning
- Analyzing diagnostic errors in the acute setting: a process-driven approach
- Morning report goes virtual: learner experiences in a virtual, case-based diagnostic reasoning conference
- Stroke hospitalization after misdiagnosis of “benign dizziness” is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods
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- Automated capture-based NGS workflow: one thousand patients experience in a clinical routine framework
- Short Communication
- Characterizing the relationship between diagnostic intensity and quality of care
- Case Reports – Lessons in Clinical Reasoning
- Lessons in clinical reasoning ‒ pitfalls, myths, and pearls: a case of confusion, disequilibrium, and “picking at the air”
- Hickam’s dictum, Occam’s razor, and Crabtree’s bludgeon: a case of renal failure and a clavicular mass
- Letters to the Editor
- Three learning concepts to improve diagnosis and enhance the practice of medicine
- Distributed cognition: a framework for conceptualizing telediagnosis in teams
- Performance of Fujirebio Espline SARS-CoV-2 rapid antigen test for identifying potentially infectious individuals
