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Occam's (Ockham's) razor vs Hickam's dictum: Lessons for treating hair loss

Occam and Hickam: Who are they and why do we care?

The most important aspect of treating hair loss is to first and foremost make sure that the correct diagnosis has been made. There are two interesting philosophical principles that I often remind myself of when working in my clinic - Occam's razor (sometimes written as Ockham's razor) and Hickam's dictum. I'd like to share them with you - and how they apply to the hair doctor.

Meet Friar Occam

Friar Occam (Ockham) was a Franciscan friar who wrote about logic, philosophy and ethics. He put forth some of his key principles way back in the 1300s. In the world of philosophy, "Occam's razor" is a helpful guiding principle. It states that if there are two explanations for an occurrence, one should generally consider the simpler explanation as being the correct one.

If you are wondering why the word 'razor' is used when apparently it has nothing to do with a razor, one must understand that the use of this word is a metaphor. In philosophy, a razor is a basic principle or rule of thumb. The word razor is used to describe the sraping away of the non essential information. Back in the day, a razor was used to scrape away ink from a page when people wrote with ink and quills.  A razor used in a similar manner to a pencil eraser. 

In medicine, we often speak of Occam's razor as a reminder that if a patient has two possible diagnoses, the simpler one is probably the more likely. Nearly every medical student remembers being told that "if they hear the sound of hoofs, they should consider first that they might be horses rather than zebras." These are the teachings of Occam's razor.

Although there are many exceptions of course, Occam's razor certainly applies in my day to day. When it comes to male hair loss, Friar Occam is often correct. Consider the patient who wonders if he has male balding or whether his recent life stress is causing his hair loss. Occam's razor says that male balding is more likely the cause. I hear many similar questions throughout my day. For many men, the simple explanation is that they are experiencing male balding:

Do you think my shampoo is the culprit, doctor?

What about my poor diet?

What about my use of a hard hat?

Occam's razor says that male balding is more likely the cause. Male balding is common and a very high proportion of  men with concerns about their hair are experiencing male balding. Of course exceptions do exist but common things being common - most men with hair loss are experiencing male balding. 

 

Meet Dr. Hickam

From Friar Occam, we turn now to John Hickam, MD. Dr Hickam was a physician and former chairman at Indiana University in the mid 1900s. Like Occam's razor, "Hickam's dictum" is also a helpful guiding principle. The principle reminds us that a person can have more than one diagnosis and one need not try to explain everything with a single diagnosis especially the simplest one. While Occam's razor reminds us to seek the simplest explanation when faced with more than once choice, Hickam's dictum reminds us that many diagnoses are possible. 

In the world of hair loss, Hickam's dictum is a more powerful guiding principle than Occam's razor. The astute hair loss physician should seek to diagnose all the reasons for a person's hair loss rather than come up with one unifying simplest explanation. Hickam's dictum most often applies to women with hair loss since women are much more likely than men to have more than one reason for hair loss. For example, it is not uncommon to diagnose androgenetic alopecia, telogen effluvium and seborrheic dermatitis all in the same patient. Yesterday, a patient had androgenetic alopecia, seborrheic dermatitis, telogen effluvium from low iron, traction alopecia from her hairpiece and trichotillomania of her eyebrows. That's five diagnoses! Clearly to best help the patient, each of the reasons must be deciphered. Hickam's dictum reminds us that there is no reason why a sixth of seventh diagnosis could not be present - so we need to look carefully.

 

Conclusion

There are many reasons to lose hair. In men, androgenetic alopecia (male balding) is by far the most common cause. From time to time, patients wish to consider an array of other possibilities for their hair loss even though the simplest explanation in these particular cases (and correct explanation) is male balding. Occam's razor reminds us to choose the simplest explanation whenever given the choice. This simple principle often applies well to men with hair loss. Hair loss in women is more complex than men and it's not uncommon for two or three diagnoses to be present. I frequently reflect on Hickam's dictum - which reminds us that many reasons can exist in the same patient and we need to consider them all!


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299



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