Friday, 7 November 2014

To choose Occam or Hickum, how astute are your specialist skills?

William of Ockham (/ˈɒkəm/; also Occam; c. 1287 – 1347) 

I saw a patient the other day that got me thinking. The patient in question had been seen by a number of specialists over the years and there was a family history of rheumatoid arthritis and fibromyalgia. The rheumatoid factor was negative, but as you are aware that does not exclude a diagnosis of rheumatoid arthritis. They were suffering with a constellation of symptoms affecting her neck, shoulders, elbows, wrists, knees and toes. Inflammatory markers namely ESR and CRP had proved normal.

Clinical examination revealed some tension around the neck area, signs in the shoulder consistent with rotator cuff tendinopathy, tennis elbow, De Quervain's tenosynovitis in the long extensor tendons of the thumb, signs of an infrapatellar bursitis and pain in the intermetatarsal space consistent with either an intermetatarsal bursitis or Morton's neuroma.

Now it would be easy to combine these symptoms together and come up with chronic widespread pain consistent with fibromyalgia syndrome, or a possible psoriatic pattern of arthropathy. The latter had been suspected and mooted to the patient by her general practitioner, but then rather unhelpfully reiterated by subsequent specialists. Therein lies the danger of using Occam's razor in diagnostics. Beware of the stage in training where one may “know a little about a lot”; when there is an awareness of diagnostic syndromes, but less of a deeper appreciation of the subtleties that may be involved in making a confident, specialist and accurate diagnosis, in other words pigeon-holing patients into a convenient diagnosis. In fact a greater challenge is to go against what previous physicians may have suspected or what the patient is worried about. This is then going towards the making the more difficult call of Hickam's dictum, where a constellation of symptoms can in fact be discreet. The principle commonly stated is that "Patients can have as many diseases as they damn well please” - as you may suspect Hickam, lived west of the Atlantic!

The ancillary investigations affirmed what I thought was going on clinically, i.e. there was no evidence of an underlying inflammatory arthropathy, I was then able to confirm my initial clinical call and put the patient on the correct treatment pathway. I think the patient was relieved, more so being given a clear message that this was not a unifying diagnosis and then receiving the correct treatments. At the same time, they questioned why they had been previously told they had inflammatory arthritis. Patients believe what they are told and what they read on the web: w+x+y+z does not always equal lupus even though you can somehow force symptoms to suit a criteria. Labelling patients with a syndrome is not helpful when they don’t actually have one! Unlabelling patients who have an incorrect syndrome is even harder. To be told that you don’t have lupus after living with the diagnosis for years is…I dread to think.

The question that I’m putting to any budding specialists in your respective fields is: do you have what it takes to question Occam and embrace Hickam? When an ancillary specialty refers to you, e.g. orthopaedics referring to rheumatology, and asks the question whether this could be e.g. polymyalgia rheumatic, rheumatoid arthritis etc, have the confidence in your convictions to disprove Occam. At the same time, you still require the basis of core specialist knowledge to be aware of more unusual syndromes to apply the razor (sub-specialism - I’ll save that for another day!). Do you now know a “lot about a little” - if so then maybe you have some of the tools required to be a specialist! Maybe my life will then become easier in the future and I can stop re-classifying patients with lupus into ANA positive tennis elbow!

By the way, if you know anyone in the UK/EU who may be interested in carrying out a PhD with our team, feel free to enquire further here or contact me on The title of the project is "Bioinformatic and functional characterization of genetic variants associated with autoimmune idiopathic inflammatory myopathy".