Discussing Normal

Normal with our hosts Andy Little, Drew Kalnow, Tanner Gronowski, and frequent guest/ honorary co-host, John Casey.

Post by Patricia Capone

Normal…it’s a word many of us have used before to describe patients, but have we ever stopped to think about what we actually mean by “normal”. Are we saying that the patient has a clinically benign physical exam, or maybe that all of their labs are unremarkable? If you ask Google, the word normal has been used in the medical field to describe someone with the absence of mental illness. However, this is often not how the word is used. So what do we really mean when we say that we have a “normal patient” and where did we all learn to use this word to describe patients?

Andy, Drew and Tanner had the pleasure of sitting down with Dr. John Casey to do a deep dive on this very interesting topic. They shared examples of how they have used the word normal to describe patients in the past and explored why it is important to take a second to think about the words we use.

John specifically gives the example of when a patient comes in with subjective back pain. The patient has no obvious cause for the pain, such as trauma, obvious injury, or arthritic changes of advanced age, and has no conclusive objective findings. At that point, with very little to go on, you have to decide whether you are comfortable treating this more conservatively or if you would rather do a more aggressive workup. In situations like this, John has found himself using the term “normal” to describe this patient when consulting another provider or talking with the nursing staff. After reflecting on instances like these, John realized that the message he is trying to convey with the word normal is that the patient made the decision to come to the ER that John would have made. Therefore, since John sees himself as a reasonable person, by association, the patient must be a reasonable person too. This conclusion and assumption often helps us to decide our comfort level with a more conservative versus a more aggressive workup for the patient in front of us.

Observations:

• Ironically, normal is often used to describe a patient when the general gestalt about the patient is unsettling. There are no obvious red flags for the patient’s presenting symptoms so we label them as an overall “normal” patient, who is presenting with symptoms that we can’t seem to pin to a diagnosis.
• We sometimes will use normal to describe a patient that we personally identify with because we often subconsciously see ourselves as normal.
• We also use the word normal to describe a patient whose diagnosis we are surprised by. We might say, “Really? That was his diagnosis? He seemed so normal.” What message are we actually trying to convey when we say this?
• Additionally, why do we define the middle-aged caucasian male presentation of myocardial infarction as “typical” or “normal” chest pain and refer to the female presentation of myocardial infarction as “atypical”?

Why is it important?

• Words matter. It is important to take stock in what we say and to reflect on why we use the words and phrases that we do.
• When we use the word normal, we may not all mean the same thing because there is no hard and fast definition. This may lead to misconceptions or give other providers preconceived notions about the patient that may unintentionally negatively affect the care that the patient receives.

What can we do?

• Reflect on your word choice.
• Ask yourself:
  • What did I mean by that?
  • What is the message I was trying to convey when I said that?
  • Is there a better way I could have described that?
• Stay open-minded
• Explore your approach to patients and consider more precise ways you can describe them

For the full discussion, check out the episode below!

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