Hickam´s dictum: an example

Death Valley. USA. 1988

A 45-years-old man had a final diagnosis of gastric adenocarcinoma with regional dissemination (peritoneum, epiplon) after a diagnostic workout of nine months. What is in the origin of this long diagnostic process? 

Three years ago he started with epigastric pain and a determination for helicobacter pylori was positive starting with specific treatment. One year and a half he was diagnosed of an intestinal infection with  Giardia Lamblia. One year before the diagnosis of gastric cancer was established he started with  epigastric pain and meteorism without improvement after antiacid treatment. He had a final diagnosis of gastric adenocarcinoma with extension to the peritoneal surface.

COMMENT: Hickam’s dictum is a counterargument to the use of Occam’s razor in the medical profession.The principle is commonly stated: “Patients can have as many diseases as they damn well please”. The principle is attributed to John Hickam, MD. Hickam was a faculty member at Duke University in the 1950s, and was later chairman of medicine at Indiana University (Wikipedia).

Probably in this case the presence of a previous non-malignant conditions have an influence on the clinical reasoning process of the doctor in charge of this patient. No casual relationship has been established between Giardiasis and gastric cancer, but in a percentage of cases this association has been detected.