American College of Physicians: Internal Medicine — Doctors for Adults ®

Friday, September 12, 2014

Occam's Razor burn

I don’t like to brag, but if there is one area of my skills as a doctor about which I am proud, it would be my skill as a diagnostician. I like to play Sherlock Holmes and figure out what’s going on with people, and I think I’m pretty good at it.

So I lied. I do like to brag … a little.

In most people’s mind’s eye, the role of diagnostician is this:

Doctor: “So Mrs. Smith, what brings you in today?”

Patient:”I feel like I am dying. I have trouble catching my breath, I am running fevers of 108 every day for the past two months, my fingers are turning black, I pass out at least two times every hour, and I’ve been vomiting up blood.”

Doctor (puts his hand in beard in a thoughtful expression): “Hmmm … sounds serious. Are there any other symptoms you have been having over the past 2 months?”

Patient: ”Well, yes, now that you mention it, I’ve got this strange rash on my feet and they’ve really started to smell bad.”

Doctor (turns to nurse with knowing expression): “Just as I suspected. That last bit of information was crucial in tying this all together. There is a rare foot fungus that causes all of your symptoms. That’s why I always need you to tell me everything so we can find the right diagnosis.” (Doctor pulls out a vial of oil from his white coat). ”Let me put this oil (which comes from the moss of a tree that only grows in Tasmania) on your feet.”

The rash vanishes and the patient’s color returns to a healthy pink glow.

Patient: “I am healed! Thank you doctor! How did you know that was the problem?”

Doctor: “Give me all the facts and I can figure out what’s wrong. Never forget the wisdom of Occam’s Razor: ‘The simplest explanation is usually the right one.’ I look for the one explanation that ties all of the symptoms together and that is usually the answer.”

As a clinician, I fantasize about being the heroic detective who notices those obscure facts that others would miss, coming up with the life saving diagnosis when all others had failed. This, unfortunately, is not how it usually works when dealing with real human patients, and my desire to find a single diagnosis to explain what is going on can actually distract me from finding the answers my patients need.

Here’s how the real interaction often goes:

Doctor: “So, Mrs. Smith, what brings you in today?”

Patient: “For the past 6 months I’ve gotten more and more tired. I just have no energy at all.”

Doctor: “Are there any other symptoms?”

Patient: “Yes, now that you mention it, I’ve been losing a lot of my hair, I am gaining weight, I’m constipated, and my skin is real dry.”

Raise your hand if you think you know the diagnosis? If you said “low thyroid,” you fell into my clever trap. Even though these symptoms are classic for hypothyroidism, I have some information you don’t: Mrs. Smith just had a battery of blood work that was completely normal, which included thyroid testing. I also know some other facts about Mrs. Smith:
• She’s married to an alcoholic.
• Her mother recently died suddenly.
• She had a hysterectomy 3 months ago.
• She has a history of bad environmental allergies.

It turns out that Mrs. Smith isn’t sleeping well at all (related to her marital situation and loss of her mother), which explains her fatigue. Inexplicably, a large percentage of my patients who don’t sleep well fail to mention this fact, instead focusing on their extreme fatigue. I point out that there is a well-established link between lack of sleep and fatigue, and that fixing sleep will go a long way in improving fatigue.

The hair loss is related to her recent surgery and the loss of her mother. There’s a condition known as telogen effluvium where a person can lose up to a third of their hair following a particularly stressful event (such as surgery or a large psychological trauma). It accounts for the vast majority of acute hair loss in my office.

Her dry skin is related to allergies, which everyone in my town seems to have, and the constipation is irritable bowel syndrome she’s having related to stress in her life.

This is not the solution Hugh Laurie would’ve uncovered on an episode of House, nor is it the glamorous deduction Benedict Cumberbatch would’ve made on Sherlock. This would make really dull television, to be sure, but it is by far the rule as to the answers I uncover as a diagnostician.

Occam’s Razor be damned.

This is frustrating. It frustrates patients who have thoroughly researched their symptoms and have come up with the “1 diagnosis to rule them all” which explains (and fixes) everything. It frustrates doctors in training who get excited when they hear the patient say “all the right things” that point to a particular diagnosis, only to be turned back by negative lab tests. Finally, it frustrates experienced doctors like me when we have patients for which only one clinical diagnosis makes sense but the data rule out the only explanation we’ve got. Yet this is reality, and we must always bow our knee to the facts before us.

Here’s how I approach diagnostic problems in the real world (you may call this “Rob’s Razor” if you want):
Listen to the story. Patients will usually tell you what is wrong with them. Pay attention to the entire history, and don’t make theories until you’ve heard everything.
Don’t assume you’ve heard everything. Even after you’ve heard everything, you are inevitably missing important information. This may be “chapter 1” of the patient story, and simply the passage of time will make a confusing story begin to make sense.
First focus on the things that pose the largest risk. Make sure chest pain is not the heart, fever and cough is not pneumonia, and abdominal pain is not appendicitis. This can be done simply by getting a clearer history, or it may require further testing.
Then address problems that are common. Common problems presenting in uncommon ways are more common than weird stuff. I look for patterns: episodic abdominal pain suggests gallbladder. Constant chest pain lasting for two days is never ischemic heart pain. Weird chest pain in a 50-year-old diabetic smoker is more worrisome than classic pain in a 20-year-old female.
The older people get, the less likely you find a single diagnosis. Pediatrics is usually simple, as kids are usually sick with one thing. Adults, on the other hand, often have multiple problems at once. You will usually be wrong if you assume all symptoms are related in an adult.
When in doubt, blame medications. I had a person recently with itching in the ear that would not stop. We tried multiple things to relieve this, but couldn’t get it better. She was taking a blood pressure pill (ACE inhibitor) which sometimes causes a relentless cough, and I remembered that chronic cough could also be caused by irritation of the ear canal. So we stopped the medication and the symptom went away. To be certain, I had her restart it, and her symptoms quickly returned. The more medications a person takes, the more likely they are having side effects.
Be willing to wait for an answer. Stories develop, and sometimes you hear things differently when you’ve heard it the 5th time. Be patient.
Accept little victories. While I like to put oil on a patient and cure their symptoms, I usually don’t hit the home run. It’s often better to aim for a 10% improvement, or improvement of a single symptom, than to fix them all at once. Over time, a bunch of 10% improvements can make a big difference.
Remember: some problems go away on their own. Some things need Father Time, not Dr. Rob, to get better.

This all gets back to my role as a physician as a helper, not a healer. I like to be the medical magician who pulls a diagnostic rabbit out of the hat, but more often I’m the hand that helps people up when they are down, making the most out of a tough situation. It’s not glamorous, but it’s the way things usually work. Accept this fact and be pleasantly surprised on the occasion when Occam is actually right.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

Labels: , , , , , ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home

This is a printer-friendly version of this page

Print this page  |  Close the preview




Contact ACP Internist

Send comments to ACP Internist staff at

Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

Powered by Blogger

RSS feed