Recognising the difference between normal and abnormal

“Would you mind if the medical student examines you as well?” It’s a common phrase in our practice (usually mentioning the medical student’s name too) and the common response from patients is positive. “Yes of course, we’ve all got to learn, don’t we?”

Although they prefer to see diseases, I also try to expose students to as many variants of normal as possible. Normal skin, normal heart sounds, normal ear drums, normal eyes, normal breathing sounds. Interestingly, ‘normal’ has a scale too – there is a wide variety.

Most students love to listen to the fascinating stories patients bring to the consulting room. They appreciate the opportunity to practise their skills on real patients – but it’s not always spectacular.

When the next person comes in with a similar problem I can see the facial expression of the student: why examine all these normal body parts? But I’ve known this patient for a while and there’s something not quite right. The patient and I both suspect it, but the medical student hasn’t picked it up yet because ‘abnormal’ is sometimes only evident when measured against normal.

“Can you feel this?” I ask, “Compare it to the patients we saw earlier.” The student tries again and eyes light up. When they learn the many presentations of normal, students become better at recognising significant deviations from normal.

Defining normality and abnormality can be challenging, even for experienced clinicians. Being able to make the call that something is a variant of normal is as valuable as identifying abnormal findings.

With the appropriate safety nets in place, it can prevent angst, misdiagnosis, overtesting, overdiagnosis and overtreatment.

Should we trust the doctor’s gut feeling?

I enjoy listening to the BBC podcast Inside Health with GP Dr Mark Porter.

One of the recent topics on the show was ‘gut feeling’. Dr Porter interviewed GP Dr Ann Van den Bruel who has done some fascinating research on this topic.

In one study, published in BMJ, Van den Bruel was able to calculate the diagnostic accuracy of the doctor’s instinct and found that it is one of the most powerful predictors of, for example, serious infections in children. One of the recommendations of the authors is:

We should certainly make clear when teaching that an inexplicable (or not fully explicable) gut feeling is an important diagnostic sign and a good reason for seeking the opinion of someone with more expertise or scheduling a review of the child.

Invaluable advice, and something most experienced GPs will do routinely. Van den Bruel: “It’s not a hundred per cent right but the chance that something serious is going on is much higher when a doctor has a gut feeling.”

It’s good to know that trusting our gut instinct may not be unscientific after all, and will add to the quality of patient care.