One of the challenges I experience in general practice is differentiating ‘normal’ from pathological. General practitioners are expected to avert missing potentially harmful conditions, while avoiding unnecessary medicalisation of benign phenomena. My preclinical medical school years emphasised how a ‘normal’ body functions; detection of pathology was developed over subsequent years with the refinement of clinical reasoning skills.
Yet the ‘normal’ of my teaching has often been disconnected from reality. Take the ‘average’ male used as our normal reference point in physiology, who is 70 kg.1 This is not the norm in Australian clinical practice. According to the Australian Bureau of Statistics, in 1995 (roughly the publication year of my physiology book), the average Australian male weighed 82 kg, and this has further increased.2 In biochemistry, we were taught normal ranges that were based on optimal human functioning; however, this is often not correlated with risk of disease. Consider normal ranges for cholesterol and lipids routinely quoted next to results, which differ from the therapeutic ranges for individual patients, depending on underlying risk factors such as diabetes.3
When it comes to children and adolescents, the task of separating normal from pathology has added challenges. Parents’ views derive from their own experiences and observations of siblings or peers. For example, when is a child or adolescent’s growth abnormal? On a number of occasions, I have seen parents who were concerned that their child was shorter or taller than siblings or other children of their age. Simply referring to population averages is often unhelpful in these situations unless a child is at the extremes. In this issue of Australian Family Physician, Taylor-Miller and Simm outline a useful approach to detecting deviations from normal that might indicate a growth disorder that requires further assessment.4
Acne is another presentation where the decision to seek medical help is often subjective. Some young people seem unperturbed by widespread cystic acne, which they perceive as a normal experience, whereas others are distressed by a small number of inflammatory comedones. As discussed by Gebauer, a large part of managing acne is education, and he outlines treatments that can be individualised to patients’ concerns.5
In their article on childhood constipation, Waterham, Kaufman and Gibb outline how the normal frequency of bowel use in children varies widely, and the prevalence of constipation in childhood can be anywhere from 3–30%, depending on the context.6 In their article on eczema management in the school-aged child, Leins and Orchard report that eczema is a common condition that many parents believe children grow out of, leading to an increasing prevalence of school-aged children with poorly managed eczema.7
Detecting depression in children is something I find particularly challenging. It involves teasing out normal childhood behaviours and developmental stages, personality types and family dynamics from serious illness. However, early identification and appropriate management can confer lifelong benefits, as discussed by Charles and Fazeli.8
In the examples above, the difficulty lies in what the word ‘normal’ actually refers to. Most frequent? Statistical average? Ideal? Minimum acceptable? In general practice, it is not only our definitions of normal we need to contend with. Patients and their families have their constructions, influenced by health beliefs, culture and social expectations. We all have patients who have diseases or impairments that, from a medical perspective, we would consider to be in need of intervention, and yet the patients do not perceive any problems. Conversely, we have patients who present with issues where we cannot detect a deviation from our concept of normal. The art of general practice is negotiating all of these concepts of normal and abnormal – our own, those of our medical teaching and those of the patient – and identifying when and how to use interventions that best support the patient in achieving the health outcomes they desire.
Sarah Mansfield FRACGP, MBBS (Hons), MSc, DCH, is a medical editor at AFP, senior lecturer in academic general practice at Deakin University, and a general practitioner in Point Lonsdale, Vic.