I’ve spent a good part of my life trying to just be normal and average (secretly I’ll always know that I’m not) and so it’s nice to now be able to declare the world abnormal based on my own personal existence. Subjective as it may be, it’s my perspective that counts. Not the patient’s. When I report to my attending, I tell them what I think: “He seemed a little depressed; She seems like she’s a little demented; I thought his hair was a little weird.” Nevermind that I don’t follow-up and ask, “You seem a little down, why is that?” or “How’s your memory recently?” I am judge, jury, and executioner of diagnosis.
Medical schools don’t typically go for the “normal” students, if they can help it. Sure, there’s plenty of talk about “well-rounded,” but around here that means having done amazing research, or having won competitive awards, or having traveled to Africa to de-worm orphans. Not a normal activity in the bunch. So it’s funny that we’re given this power of normalcy. Doctor’s probably don’t fit the “normal” curve much better, either: they make more money than the average person, they have much more education, they’re more likely to get divorces and more likely to smoke.
I don’t know, however, that there’s a better system. Human behavior is just so diverse, so out there, that you have to hope that a physician gets a good idea of “within normal limits” because he or she has seen so many patients, and is intelligent enough to pick up on clues of abnormal.
Culture throws a cog into the well-greased normal machine, however. We’re trained now to recognize some of the big cultural differences: some cultures make decisions based on a community’s decision, rather than an individual one; others bring many family members to hospital visits; some want to care for their loved ones at home, while others feel that a skilled nursing facility is a better choice. I think one can get a sense of the obvious, outward cultural differences pretty easily, but it’s the subtle, internal assumptions that each party maintains that are much harder to address. Not that this is limited to ethnic culture, either–it’s probably just as common between families. (For example: I always find it fascinating how different families celebrate a holiday. In my house, we got to open one present on Christmas Eve, and left everything else until the next morning. Other families open everything on Christmas Eve night, or open them with their neighbors, or don’t even celebrate Christmas at all. Anything but my version seems weird to me.)
I have an assumption that pretty frequently gets me into trouble, and I have to constantly remind myself to break: I assume that if a patient has a problem, he or she will tell me about it. Is this an incorrect assumption? Absolutely, but from my own experience, I tell my physician every little ache and pain, and so I assume that’s how other people’s minds work. But you’d be surprised how often people don’t mention something until you ask them directly, or rephrase the question.
Me: Any other problems or difficulties I can help you with today?
Pt: No, I’m doing pretty well, I’d say.
Me: Do you have trouble with urination?
Pt: Oh, no, I’m fine.
Me: Are you waking up to pee at night?
Pt: Yes, about 5 or 6 times a night.
It’s difficult for me sometimes, because in many ways I’m an introvert. I internalize things, I think constantly but don’t say most of what I’m thinking aloud. And unless I ask, or say the thing I’m thinking out loud, I have no way of confirming what I’m thinking.