Occam's Razor versus Hikam's Dictum. (Hikam's What?)

[mycrofft]

:huh:

I have a new all-time 'til now favorite wikipedia entry: Hikam's Dictum.
http://en.wikipedia.org/wiki/Hickam%27s_dictum

"Patients can have as many diseases as they damn well please".
Comments?

 

[MexDefender]

Hikam's Dictum could lead to over-diagnosing which in many cases it already has. Doctors not using Occam's Razor instead thinking outside the box which is good if it were a complicated aliment but it most likely isn't.

An example would be the over-diagnosing of ADD/ADHD. If pt's can have as many diseases as they damn well please, it would be a brave new world for medical professionals.

 

[Veneficus]

Hikam's Dictum could lead to over-diagnosing which in many cases it already has. Doctors not using Occam's Razor instead thinking outside the box which is good if it were a complicated aliment but it most likely isn't.

An example would be the over-diagnosing of ADD/ADHD. If pt's can have as many diseases as they damn well please, it would be a brave new world for medical professionals.

I disagree,

I think the worst medical care comes from doctors who base their treatments soley on epidemiological guidlines. (I shouldn't hate them too much though, they keep the ICU full of septic patients)

It is the same problem mid-level providers suffer from.

Everything they see is the most common illness until their treatment doesn't work and the patient is finally sent to a doctor.

It trickles right down to the same rigid "protocol, guidline, SOP, Etc." way of thinking and performing.

While it is true it probably works most of the time, the patient in front of you doesn't care what works for most people. They only care what works for them.

I would bet the same people who "support" treatment by numbers for everyone else are the same people that get mad when a doctor spends 8 minutes with them and doesn't actively listen because he is mentally searching for what guidline that patient falls under and directing the questioning to do it.

 

[Aidey]

Am I the only one that doesn't think the two are incompatible?

I interpret Occam's Razor to mean the simplest explanation is the most likely. Which means that the pt with a blood nose is more likely to have HTN than Ebola. It doesn't mean they can't have HTN and VonWillebrands.

 

[MexDefender]

I disagree,

I think the worst medical care comes from doctors who base their treatments soley on epidemiological guidlines. (I shouldn't hate them too much though, they keep the ICU full of septic patients)

It is the same problem mid-level providers suffer from.

Everything they see is the most common illness until their treatment doesn't work and the patient is finally sent to a doctor.

It trickles right down to the same rigid "protocol, guidline, SOP, Etc." way of thinking and performing.

While it is true it probably works most of the time, the patient in front of you doesn't care what works for most people. They only care what works for them.

I would bet the same people who "support" treatment by numbers for everyone else are the same people that get mad when a doctor spends 8 minutes with them and doesn't actively listen because he is mentally searching for what guidline that patient falls under and directing the questioning to do it.

The problem with that is doctors are already trained and equip to diagnose patients based on various symptoms they present. you would be opening a can of worms to say :censored::censored::censored::censored: it he might have liver failure because of a chronic pain, the simplest answer is usually the most correct.

If the doctor is incapable of thinking on his own after the many years of study than it falls on the education he/she was provided that made the doctor incompetent.

It isn't so much as treatment by numbers as it is treatment by fact, the fact is majority of the cases are always going to be the same so they treat accordingly. Bogging down the system by treating everyone like an individual only slows the process of treatment and effective treatment. You are not tied down to your family doctor, that is why they let you get a second opinion...

People should take control of their own health and if they feel the treatment or diagnosis is inadequate than they should do something about it but to have doctors start throwing out multiple diagnosis that would lead to confusion and more cases of misdiagnosis.

 

[NYMedic828]

The problem with that is doctors are already trained and equip to diagnose patients based on various symptoms they present. you would be opening a can of worms to say :censored::censored::censored::censored: it he might have liver failure because of a chronic pain, the simplest answer is usually the most correct.

If the doctor is incapable of thinking on his own after the many years of study than it falls on the education he/she was provided that made the doctor incompetent.

It isn't so much as treatment by numbers as it is treatment by fact, the fact is majority of the cases are always going to be the same so they treat accordingly. Bogging down the system by treating everyone like an individual only slows the process of treatment and effective treatment. You are not tied down to your family doctor, that is why they let you get a second opinion...

People should take control of their own health and if they feel the treatment or diagnosis is inadequate than they should do something about it but to have doctors start throwing out multiple diagnosis that would lead to confusion and more cases of misdiagnosis.

You aren't going to win this argument when you are talking to the guy whose job is to expect the unexpected and know how to fix it when the other doctor doesn't...

 

[Veneficus]

I don't think you understand quite how it works.

You don't simply write a diagnosis and treat for it.

You explore for a diagnosis based on history, physical, and adjuncts to a physical.

It is in the best interest of a patient and the medical system to be as accurate as possible.

A good example would be primary and secondary hypertension.

You could easily Dx hypertension and treat the patient for the rest of their life, however, discovering a reversible cause of hypertension with its own unique treatment can not only be cheaper in the long run, it can improve quality of life and make a lot of money with an increase in productive life.

The problem with that is doctors are already trained and equip to diagnose patients based on various symptoms they present. you would be opening a can of worms to say :censored::censored::censored::censored: it he might have liver failure because of a chronic pain, the simplest answer is usually the most correct..

There is no such thing as uncomplicated chronic pain. Nociceptive pain is caused by injury. Discovering and treating the source of injury is far more efficent than simply writing a script for pain meds.

If the doctor is incapable of thinking on his own after the many years of study than it falls on the education he/she was provided that made the doctor incompetent...

That doesn't quite work either. The medical reimbursement system has demanded "evidence based" diagnostics and treatments. Which means, if you want paid, you will follow the guidelines, even when you know they do not apply.

Furthermore, particularly in the US, not following a guideline, even if you know prior to starting will not work, you open yourself up for potential litigation.

It is in the doctors financial and professional interest not to deviate from the guidelines, but to run through them in order. It doesn't mean they do not know or are incapable.

Let me give you an example.

In septic neonates, a late complication is abdominal distension. Long story short, when you see it, it is probably too late to do anything, however, several treatments are recommended. (including peritoneal dialysis despite the pathology being from gut ischemia, which means the blood flow doesn't work anyway)

In adults it is permissible (read paid for) to put a urinary catheter that measures bladder pressure. The increase in bladder pressure clues to a subclinical increased interabdominal pressure. Which permits early identification and treatment.

There is no guidelinefor the same technique in neonates, and consequently not only may the cost not be reimbursed, but again, by doing something not in the guidline, causes exposure to potential liability.

You know why the treatment isn't in the guideline? Because nobody I know will deviate from it or can get ethical approval to try.

It isn't so much as treatment by numbers as it is treatment by fact, the fact is majority of the cases are always going to be the same so they treat accordingly.

:rofl::rofl::rofl:

a majority of presentations are usually from the most common disease process, but that does not excuse a physician from ruling out other differentials. That requires entertaining less common pathologies to some degree.

You "chronic pain" being a common diagnosis, will not excuse a misdiagnosis of mets in the liver. Nor will treating a neoplasm in the liver as primary colon cancer (the most common reason for neoplasmsin the liver) excuse you if the actual problem is hepatocellular carcinoma.( a primary liver cancer often associated with hep B)

Bogging down the system by treating everyone like an individual only slows the process of treatment and effective treatment. You are not tied down to your family doctor, that is why they let you get a second opinion...

That is simply not true.

Do you think diet and exercise modification is not a better treatment for primary HTN than an ace inhibitor?

If you do not look at the individual in detail, how do you plan to come up with a proper modification?

People should take control of their own health and if they feel the treatment or diagnosis is inadequate than they should do something about it

Really? Tell me then, without medical education, how does a person decide a diagnosis or treatment is inadequete?

What is the definition of inadequete?

To whom?

but to have doctors start throwing out multiple diagnosis that would lead to confusion and more cases of misdiagnosis.

Actually, it doesn't.

You see, at some point, it may be impossible to settle on a final diagnosis. So the only solution is to attempt to treat one from the list you have.

It may not be the proper Dx, it will certainly be a treatment that likely won't work if it is. When it doesn't, on the follow up you then make alterations.

You explore if the treatment is actually not affecting the pathology or if the individual doesn't tolerate the treatment well.

Have you ever seen a patient with CHF, COPD, pulmonary HTN, and chronic smoker complain of difficulty breathing or caugh?

Tell me?

What is the Dx causing it and what is the treatment?

 

[mycrofft]

"It isn't so much as treatment by numbers as it is treatment by fact, the fact is majority of the cases are always going to be the same so they treat accordingly".

That is insurance-speak. You can't treat statistics, although I agree you must have the most likely answer in mind as a likely diagnosis. Even if you are using complaint-initiated evals, you have to keep your sense and sense open for potential outriders. Example: "indigestion" and a sore shoulder is most likely due to someone taking too many NSAIDS for shoudler pain, but it could also mean ischemia and impending MI. Or other abdominal or chest pain with referral.

"Bogging down the system by treating everyone like an individual only slows the process of treatment and effective treatment."

I hope you are being sarcastic. Ther are ways to manage an inteview and one of them is to know when a little extra time will pay dividends. I get your point, but the answer is more practitioners, not less time per pt.

"You are not tied down to your family doctor, that is why they let you get a second opinion..."

Not all insurance allows that, especially indigent programs and other government programs. I agree about "taking charge" of your health care as you said later is important, but if we could all do that, we wouldn't need primary care MD's, we'd just walk into specialists' and diagnosticians' offices on our own.

I appreciate the viewpoint, I disagree on those areas based on my age ( ) experience including as a case manager, and working in a very pressured primary care environment.

 

[MexDefender]

I don't think you understand quite how it works.

You don't simply write a diagnosis and treat for it.

You explore for a diagnosis based on history, physical, and adjuncts to a physical.

It is in the best interest of a patient and the medical system to be as accurate as possible.

A good example would be primary and secondary hypertension.

You could easily Dx hypertension and treat the patient for the rest of their life, however, discovering a reversible cause of hypertension with its own unique treatment can not only be cheaper in the long run, it can improve quality of life and make a lot of money with an increase in productive life.




There is no such thing as uncomplicated chronic pain. Nociceptive pain is caused by injury. Discovering and treating the source of injury is far more efficent than simply writing a script for pain meds.



That doesn't quite work either. The medical reimbursement system has demanded "evidence based" diagnostics and treatments. Which means, if you want paid, you will follow the guidelines, even when you know they do not apply.

Furthermore, particularly in the US, not following a guideline, even if you know prior to starting will not work, you open yourself up for potential litigation.

It is in the doctors financial and professional interest not to deviate from the guidelines, but to run through them in order. It doesn't mean they do not know or are incapable.

Let me give you an example.

In septic neonates, a late complication is abdominal distension. Long story short, when you see it, it is probably too late to do anything, however, several treatments are recommended. (including peritoneal dialysis despite the pathology being from gut ischemia, which means the blood flow doesn't work anyway)

In adults it is permissible (read paid for) to put a urinary catheter that measures bladder pressure. The increase in bladder pressure clues to a subclinical increased interabdominal pressure. Which permits early identification and treatment.

There is no guidelinefor the same technique in neonates, and consequently not only may the cost not be reimbursed, but again, by doing something not in the guidline, causes exposure to potential liability.

You know why the treatment isn't in the guideline? Because nobody I know will deviate from it or can get ethical approval to try.



:rofl::rofl::rofl:

a majority of presentations are usually from the most common disease process, but that does not excuse a physician from ruling out other differentials. That requires entertaining less common pathologies to some degree.

You "chronic pain" being a common diagnosis, will not excuse a misdiagnosis of mets in the liver. Nor will treating a neoplasm in the liver as primary colon cancer (the most common reason for neoplasmsin the liver) excuse you if the actual problem is hepatocellular carcinoma.( a primary liver cancer often associated with hep B)



That is simply not true.

Do you think diet and exercise modification is not a better treatment for primary HTN than an ace inhibitor?

If you do not look at the individual in detail, how do you plan to come up with a proper modification?



Really? Tell me then, without medical education, how does a person decide a diagnosis or treatment is inadequete?

What is the definition of inadequete?

To whom?



Actually, it doesn't.

You see, at some point, it may be impossible to settle on a final diagnosis. So the only solution is to attempt to treat one from the list you have.

It may not be the proper Dx, it will certainly be a treatment that likely won't work if it is. When it doesn't, on the follow up you then make alterations.

You explore if the treatment is actually not affecting the pathology or if the individual doesn't tolerate the treatment well.

Have you ever seen a patient with CHF, COPD, pulmonary HTN, and chronic smoker complain of difficulty breathing or caugh?

Tell me?

What is the Dx causing it and what is the treatment?

I do but you only want to see it your way.

You misunderstood the chronic pain example.

Then that is the system working against doctors who should enact change.

Sigh... You again understand but being obtuse, majority not minority.

Again... What I meant is if we treat everyone like they are unique in most cases they will not be which could be determined by your physician over years of seeing you. Proper modification, over statistical findings.

Obtuse apparently. If the diagnosis comes back and treatment is given but is not effective at combatting sypmtoms than you get a second opinion.

Combatting symptoms as a treatment without reaching a diagnosis is what is wrong with healthcare... It works for a time but you should realize its only until you can come up with a cure/treatment that "solves" the problem.

 

[NYMedic828]

I do but you only want to see it your way.

You misunderstood the chronic pain example.

Then that is the system working against doctors who should enact change.

Sigh... You again understand but being obtuse, majority not minority.

Again... What I meant is if we treat everyone like they are unique in most cases they will not be which could be determined by your physician over years of seeing you. Proper modification, over statistical findings.

Obtuse apparently. If the diagnosis comes back and treatment is given but is not effective at combatting sypmtoms than you get a second opinion.

Combatting symptoms as a treatment without reaching a diagnosis is what is wrong with healthcare... It works for a time but you should realize its only until you can come up with a cure/treatment that "solves" the problem.

Under what grounds are you claiming he only wants to see it his way? You don't know the first thing about being a physician and nor do I. You are just fabricating these ideas of what you believe to be a proper system when in reality that system is flawed and is actually an outline for substandard medical care.

Do you even realize that in your protest to Vene, a physician, you are only willing to see it YOUR way? Pretty hypocritical in my book.

You are stating that physicians should just treat patients like they are on an assembly line.

When I go to see my PCP, I expect to treated as an individual and feel like the physician is actually trying to do something for me instead of just get me out of his office and get paid.

 

[MexDefender]

Under what grounds are you claiming he only wants to see it his way? You don't know the first thing about being a physician and nor do I. You are just fabricating these ideas of what you believe to be a proper system when in reality that system is flawed and is actually an outline for substandard medical care.

Do you even realize that in your protest to Vene, a physician, you are only willing to see it YOUR way? Pretty hypocritical in my book.

You are stating that physicians should just treat patients like they are on an assembly line.

When I go to see my PCP, I expect to treated as an individual and feel like the physician is actually trying to do something for me instead of just get me out of his office and get paid.

Maybe it wasn't obvious to you. Like mycrofft disagreed but was mature about it.
Mmm no but I can see where you saw that.

I saw Hikams Dictum view point but think Occams Razor is more correct.

Beyond being obtuse I didn't attack the person but the arguments that were not so subtle with snide comments.

Assumptions win arguments - but really I didn't see any consideration to the contrary

 

[Aidey]

Not to repeat myself but...

You could also consider that they aren't automatically mutually exclusive. Occam's Razor to mean the simplest explanation is the most likely. Which means that the pt with a bloody nose is more likely to have HTN than Ebola. But it doesn't mean they can't have HTN and VonWillebrands.

 

[Veneficus]

Then that is the system working against doctors who should enact change.

You are rather idealistic in this.

In medicine, it is money that drives change, not doctors. Particularly the people who pay.

I wouldn't say systems work against doctors so much as those uneducated in medicine need a way to demonstrate they get something for their money.

At the currect time, it is the best that can be done in the whole world. In every country.

Do you have a suggestion or plan to change it?

Again... What I meant is if we treat everyone like they are unique in most cases they will not be which could be determined by your physician over years of seeing you. Proper modification, over statistical findings.

You are simply in error about people not being unique. From HLA matching to molecular receptors, enzymes, DNA, etc, if you haven't heard, the future of medicine is treatments custom made for each individual.

Probably not in my lifetime, but if you knew as much as you think, you would know that even common diseases like HTN have populations of people that do not respond to the treatments.

It is not that the doctor doesn't know what he is doing and you need a second opinion, it is that medicine is not like going to McDonalds, you do not see a menu to select from and then if it doesn't turn out perfectly the first time go over to Burger King.

That actually costs more, takes more time, and in most cases will not even get you closer to the treatment you need.

If the diagnosis comes back and treatment is given but is not effective at combatting sypmtoms than you get a second opinion..

Diagnosis comes back from where? Do you think you just send out some labs and get a nice printout of what is wrong with a patient?

A second opinion for what? Because a treatment isn't working how you want? You do know that many medications cause side effects. The exact same disease in 2 different people may not respond to the exact same medication.

Treatment is sometimes a process. Everytime you "doctor hop" it delays that treatment.

Combatting symptoms as a treatment without reaching a diagnosis is what is wrong with healthcare...

You do realize the only people who ever reach an accurate diagnosis most of the time are pathologists right?

In many diseases, mankind lacks the knowledge and ability to do anything but treat the symptoms.

It works for a time but you should realize its only until you can come up with a cure/treatment that "solves" the problem.

I can count on one hand actual "cures" in all of medicine. Treatments largely do not cure or solve problems, they permit compensation or increase function.

You seem to have a very fantastic opinion of what medicine actually is and does.

 

[mycrofft]

"I can count on one hand actual "cures" in all of medicine. Treatments largely do not cure or solve problems, they permit compensation or increase function".

We buy the organism time to achieve homeostasis, either through resumption or readjustment. And give out lollipops to the kids, too.

How about this: Occam's for each individual malfunction, but Hikam's for the holistic meldin of all the blades' on....Occam's Swiss Army Knife?


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