A Peek into How Doctors Think – An Introduction to “Columns”
Anyone who is on their path to becoming a successful physician needs to be able to take a good history and perform a thorough physical. However in this day and age, patient care is performed in a very speedily process and thus the boards test a medical student on how succinctly they can perform a patient history.
Thus students and licensed medical providers need to be adept at “data gathering” no matter what the patient presents with. Our job is to figure out what’s going on, no matter how difficult the task, and do so quickly. So how do we accomplish this?
We start by looking at the cause and then breaking down what could be occurring resulting in that cause, or in other words, forming a differential diagnosis. So if someone has chest pain, one may form a differential consisting of heart attack, pericarditis and costochondritis. But other issues may be at play such as a pneumonia or an esophagitis.
So when we look at a person with chest pain, we consider all the body parts or causes that could be causing the symptoms.
Hence with a patient presenting with chest pain, one would consider a cardiovascular cause, pulmonary cause, gastrointestinal cause, musculoskeletal cause, and even psychiatric cause.
This is the basis of forming one’s columns. For every chief complaint we form columns either mentally or on paper and then ask associated symptoms (or pertinent positives or negatives) to determine which column we’re in. Usually a few “power questions” will help discriminate which column you are in. Once you hit the correct column you will ask further questions along that line.
True there are many more questions we could ask than just the “power questions,” but during a time crunch we need to ask very specific ones to determine if we are on the right track. If we receive multiple “no”s along a column, we know to move onto the next column.
Hence if a patient with chest pain denies dizziness and diaphoresis or sternal pain upon palpation but admits to cough, shortness of breath and sputum production, we have just narrowed down the chest pain patient to a pulmonary cause as opposed to assuming it was cardiac in nature. Then we would continue down the pulmonary column, thinking our differential may be a pneumonia/bronchitis/pulmonary embolism, and ask about hemoptysis, fever, chills, etc.
So for each patient one must create columns depending on the chief complaint and then ask power questions to help focus down your differential.
Now these columns can also assist with the physical exam component of data gathering. If the above patient presenting with chest pain could have a cardiac/pulmonary/GI/musculoskeletal condition, one would examine his heart, lungs, upper abdomen and palpate the sternum and ribs.
For an added bonus, the columns can additionally assist one in forming their differential for the SOAP note.
Chest pain r/o
If a case involves a not so clear-cut symptom, columns could be used as well.
For example a patient presenting with hair loss. If one complains of hair loss, a variety of differentials could be at play. One column could be an endocrinology source (such as hypothyroidism or diabetes), another could be psychological (such as stress or trichotillomania), a third could be medications (such as chemotherapy agents), and a fourth could include genetics. Narrowing these down with power questions could exclude non-contributing columns.
So whether it’s a direct body system or cause, columns help one focus down the differential and allow an easy visual that enables one during a timed test to think quickly and know which questions to ask.
Again these columns are instituted after the History of Present Illness in which a student obtains onset/chronology, palliative/provocative factors, quality of symptoms, radiation, severity and timing (OPQRST).
They will be written down in the SOAP note after the HPI.
Example: Mary is a 25-year-old female presenting with acute onset right foot pain. It began 6 hours ago after she went for a job. Ice provides some relief but walking on it worsens the pain. The pain is sharp, constant with a severity of 7/10. She denies fever, chills, open wounds, swelling, redness, temperature changes, numbness or tingling.
Since during this step in the history most medical students find it challenging to know “which questions to ask.” The columns and power questions simplify this.
To learn this method to improve one’s data gathering skills click here.