Aberegg Scott K, Poole Brian R, Locke Brian W
Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Salt Lake City, USA.
Department of Pulmonary and Critical Care, Intermountain Medical Center Shock Trauma ICU, Murray, UT, USA.
J Gen Intern Med. 2024 Oct 28. doi: 10.1007/s11606-024-09120-y.
Hickam's dictum ("a patient can have as many diseases as he damn well pleases") has been touted as a counterargument to Ockham's razor, which enjoins clinicians to seek a single, simple, or unifying diagnosis. Yet the phenomenon of multiple diagnoses has not been formally analyzed.
We evaluated multiple diagnoses using three methods of inquiry: (1) a review of 83 case reports; (2) a review of 220 cases from the New England Journal of Medicine; and (3) an online survey of providers' intuitions.
Eighty-three published case reports claimed to instantiate Hickam's dictum or violate Ockham's razor. All reported a primary diagnosis that explained the presenting illness, and one or more additional diagnoses which could be classified into four categories: (1) an incidentaloma (n = 21; 25.3%); (2) a pre-existing disease (n = 26; 31.3%); (3) a disease causally linked to the primary diagnosis (n = 33, 39.8%); and (4) a causally unrelated second disease contributing to the acute presentation (n = 3, 3.6%). Among 220 cases from the New England Journal of Medicine, all reported a unifying final diagnosis. In an online survey, 265 respondents recruited using social media evaluated four hypothetical cases with multiple diagnoses representing this categorization scheme. A majority of respondents (79%; 95% CI, 74-84%) chose the case representing category 4 - a coincident, causally unrelated second diagnosis - as the most unlikely or surprising diagnostic combination.
Multiple diagnoses commonly occur. However, the majority of the multiple diagnoses we analyzed were causally linked, or represented incidentalomas or known pre-existing diseases. These diagnostic combinations were unsurprising to a majority of surveyed providers. We show that multiple diagnoses can be arranged in a framework that considers time, probability, and causation. This framework reconciles the alleged conflict between Hickam's dictum and Ockham's razor and has greater practical and pedagogical utility.
希卡姆格言（“患者可以患有他乐意患有的尽可能多的疾病”）被吹捧为对奥卡姆剃刀原则的一种反驳，奥卡姆剃刀原则要求临床医生寻求单一、简单或统一的诊断。然而，多重诊断现象尚未得到正式分析。
我们使用三种探究方法评估多重诊断：（1）回顾83份病例报告；（2）回顾《新英格兰医学杂志》上的220例病例；（3）对医疗服务提供者的直觉进行在线调查。
83份已发表的病例报告声称体现了希卡姆格言或违反了奥卡姆剃刀原则。所有报告都有一个解释当前疾病的主要诊断，以及一个或多个额外诊断，这些额外诊断可分为四类：（1）偶发瘤（n = 21；25.3%）；（2）既往疾病（n = 26；31.3%）；（3）与主要诊断有因果联系的疾病（n = 33，39.8%）；（4）对急性表现有影响的无因果关系的第二种疾病（n = 3，3.6%）。在《新英格兰医学杂志》的220例病例中，所有病例都报告了一个统一的最终诊断。在一项在线调查中，通过社交媒体招募的265名受访者对代表这种分类方案的四个具有多重诊断的假设病例进行了评估。大多数受访者（79%；95%置信区间，74 - 84%）选择代表第4类的病例——一种巧合的、无因果关系的第二种诊断——作为最不可能或最令人惊讶的诊断组合。
多重诊断很常见。然而，我们分析的大多数多重诊断是有因果联系的，或者是偶发瘤或已知的既往疾病。这些诊断组合对大多数接受调查的医疗服务提供者来说并不意外。我们表明，多重诊断可以安排在一个考虑时间、概率和因果关系的框架中。这个框架调和了希卡姆格言和奥卡姆剃刀原则之间所谓的冲突，具有更大的实践和教学效用。
