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.
Before I get to the teacher in question, I want to talk education for a minute. It's been written many times that U.S. students are, well - not number one. They are not number one in math, not number one in science and not number one in reading/writing. In fact, they are far from number one. The World Education Ranking system ranks, as you can guess - education in the world. The U.S. has never been number one. Ever. In 2016 U.S. kids had their best showing since the 70’s and placed 7th, but in 2017 dropped to 20th and last year (2018) - the U.S. dropped off the list entirely.
But you know what U.S. kids are number one in - thinking they are number one. No, seriously. If you ask U.S. kids how they expect to perform on a test when up against kids from other countries, American children universally believe they will perform much, much, much better than they actually do. And many U.S. kids honestly believe they will be number one in math, science, literacy and pretty much everything else under the sun. Number. One.
Well, let’s take a look. There is a test called the PISA (Program for International Students Assessment) and it’s a worldwide exam administered approx. every three years to 15 year old's in 72 countries. About half a million students take the exam. The test results are compiled by the OECD (Organization for Economic Cooperation and Development). Their most recent test was in 2015.
Out of 72 countries tested:
U.S. kids ranked 40th in math with a score that puts U.S. teens 11 spots lower than the average score.
U.S. kids ranked 24th in reading comprehension with a score that puts U.S. teens 4 spots higher than the average score.
U.S. kids ranked 25th in science with a score that puts U.S. teens 4 spots higher than the average score.
Not exactly “‘We’re number one!” And, sadly, according to those 17'-18'World Education Ranking numbers I posted above, it looks like U.S. kids are dropping further down the list.
So, what’s going on? Who’s to blame?
Well, I don’t really know and I’m not going to speculate much; however, I find it interesting to hear how much self confidence U.S. kids seem to have vs. how they actually perform. Keep in mind, just because I’m not going to speculate doesn’t mean that other folks won’t speculate. Hell, everyone seems to have all the answers these days, you know? Just check social media where everyone is certain their all caps FB post is clearly the one and only way you MUST think or they’ll unfriend you.
It seems as if parents blame teachers. Teachers blame parents. Republicans blame teachers. Democrats blame the system. Education administrators don’t seem to blame teachers, but they certainly bail out on protecting teachers when irate parents come screaming or, God forbid - someone on a sports team is failing! “You can’t fail our basketball/baseball/football star!”
Yes, yes teachers can and should be able to fail students up to and including athletes. It is the teacher's exact job to evaluate if a child has done the work to pass, or not. If kids are terrible s#!t heads and parents are ignoring email, after phone call after text message saying, “Hey - your kid is a bully, hasn’t turned in 10 of his assignments this year and I might have to fail him! Please respond!” Well, if parents don’t take a vested interest in their own child’s education and their kid acts a damn fool and never does his/her school work - that kid deserves consequences. Just sayin.
And that’s exactly how Julie Marburger felt. Marburger is a sixth grade teacher at Cedar Creek Intermediate School in Texas. She was worn down by the chaotic destructive students and the irate road raging parents. And so, just before she quit, she wrote an epic FB post blasting them all. The rant went viral and within two weeks had millions of hits. (Editor’s note: It doesn’t appear as if she quit. She expected to receive hatred for her post and thought she would have to quit as a result but instead of recieving negative press she has received overwhelming support and it sounds as if the support has stayed her hand from quitting, as of yet).
Marburger’s view is that parents and children have become awful, abusive, entitled pricks. The kids don’t seem to care about consequences and parents lose their minds if their Precious Angel doesn’t get an A. It doesn’t matter if Precious Angel destroys school property, turns in zero work assignments and verbally abuses teachers and/or students because parents will still demand that Precious Angel recieve an A! After two years of, as Marburger describes it - abuse, she finally had enough and called parents and students out for their behavior.
Her full FB post:
“I left work early today after an incident with a parent left me unable emotionally to continue for the day. I have already made the decision to leave teaching at the end of this year, and today, I don’t know if I will make it even that long. Parents have become far too disrespectful, and their children are even worse. Administration always seems to err on the side of keeping the parent happy, which leaves me with no way to do the job I was hired to do ... teach kids.
I am including photos that I took in my classroom over the past two days. This is how my classroom regularly looks after my students spend all day there. Keep in mind that many of the items damaged or destroyed by my students are my personal possessions or I purchased myself, because I have NO classroom budget. I have finally had enough of the disregard for personal and school property and am drawing a line in the sand on a myriad of behaviors that I am through tolerating. Unfortunately, one parent today thought it was wrong of me to hold her son accountable for his behavior and decided to very rudely tell me so, in front of her son.
Report cards come out later this week, and I have nearly half of my students failing due to multiple (8-10) missing assignments. Most of these students and their parents haven’t seemed to care about this over the past three months, though weekly reports go out, emails have been sent and phone calls have been attempted.
But now I’m probably going to spend my entire week next week fielding calls and emails from irate parents, wanting to know why I failed their kid. My administrator will demand an explanation of why I let so many fail without giving them support, even though I’ve done practically everything short of doing the work for them. And behavior in my class will deteriorate even more. I am expecting this, because it is what has happened at the end of every other term thus far.
I have never heard of a profession where people put so much of their heart and soul into their job, taking time and resources from their home and family, and getting paid such an insultingly measly amount. Teachers are some of the most kind and giving people I have ever met, yet they get treated so disrespectfully from all sides. Most parents can’t stand to spend more than a couple hours a day with their kid, but we spend 8 with yours and 140 others just like him. Is it too much to ask for a little common courtesy and civil conversation.
It has been a dream of mine for as long as I can remember to have a classroom of my own, and now my heart is broken to have become so disillusioned in these short two years. This is almost all i hear from other teachers as well, and they are leaving the profession in droves. There is going to be a teacher crisis in this country before too many more years has passed unless they abuse of teachers stops.
People absolutely HAVE to stop coddling and enabling their children. It’s a problem that’s going to spread through our society like wildfire. It’s not fair to society, and more importantly, is not fair to the children to teach them this is okay. It will not serve them towards a successful and happy life.
Many will say I shouldn’t be posting such things on social media ... that I should promote education and be positive. But I don’t care anymore. Any passion for this work I once had has been wrung completely out of me. Maybe I can be the voice of reason. THIS HAS TO STOP”
As we turn the bend during the second semester of the school year we begin to face challenges. For many of us the material seems insurmountable….maybe we perceive it as such, or maybe teachers realize they are falling short and rush to get all the information in before the school year ends.
Either way, students feel stressed, overwhelmed and many times unable to catch up. So what do you do when you find the material to be TMTH (too much to handle)?
Firstly, realize that you don’t have to learn everything. Remember, the professor can’t test on EVERYTHING. So don’t go at a packet, slide deck or book with the attitude that you have to know everything. Find the Titles, the main point in the paragraph that follows, and any supporting info that seems to buttress the main point. Careful with your use of highlighting if you’re tired and burning out because you’ll start to highlight everything. Which brings us to….
Two heads are better than one. Sometimes three…but more than that may be distracting. What you thought was important in class or on a sheet of information can be confirmed or denied by another student. Moreover everyone has strengths and weaknesses so find one who can compliment you and help you discern what’s important to know.
Rather than guessing, take 15 minutes to meet with the teacher to get an idea of what they find imperative to learn/know for the test. But don’t go into their office asking “will this be on the test?” I would be direct, honest, but humble by asking:
Now, many times the professor will oblige. But if not, you need to indirectly determine what he/she is going to test. This brings us to…..
How was the material given?
If your professor brushed over it quickly in class, it could mean they don’t find it crucial enough to test or ….they don’t completely understand the material themselves. Most likely this will not be tested. However, if he/she brushed over it because it was given in a previous lecture, then its open game.
Demonstrations of the brush over include:
Are they big on testing if you paid attention in class or knowing the information that’s necessary to succeed? Are they a jerk and will pick the most esoteric piece of content from a 1000 word slide or will they focus on main points? Get an idea on what makes them tick.
For some institutions the exam is to test competency. These are the most clear-cut, fair tests and to me, make the most sense. If, for example, in medical school one is studying poor lung function and what a spirometer discerns, the inventor and history of the tool will most likely not be tested. Keep in mind, your professor has bosses and they have bosses, so your competency reflects on them.
For other institutions it may be at the professor’s discretion. So you need to feel out each teacher and see what they’re all about. If they are big on class attendance and will weight the test towards those who showed up, expect questions on content that was highlighted in class. And if they are big on seeing if you paid attention, you will be tested on something they impressed upon you sometime during lecture. So during the lecture watch for the following:
So after you’ve done your “homework,” how do you tackle your studies?
Your time is divisible so grab a calculator and aliquot into equal periods. Make sure you have extra sessions included for breaks and catch up sessions. Or you can use a calendar that is already compartmentalized on which to create your timetable.
Clean your desk!
A nice clean, crisp desk with plenty of pens and highlighters helps energize one more than cluttered paper. Moreover have a second work space you can go to when you get sick of working at your desk.
Now this is easier said than done. Some will put their hardest classes on their study calendar first, some the easiest. There are pros and cons to both. What I suggest is alternating difficult and easy subjects. You need the start of your day and initial power hours knocking out the difficult material, but then the easier classes will boost your confidence and sometimes energy. So one option could be:
Take real breaks!
You should design two types of breaks: Short and Long.
Your short break should be no shorter than 10 minutes. During the break you must do the following:
Your long break should be no shorter than 45 minutes. During these breaks you can:
If you’re “going through the motions” of studying and feel “burnt” you won’t be absorbing the material and subsequently you’ll be wasting precious hours. You must identify burnout by looking for the following:
When studying you’re classwork it’s difficult to avoid the boredom and stress, but the following may help:
Remember, we’ve all been there and school is supposed to be challenging. Stay on course and get help if you need such as a tutor. We all make it to the finish line….even if we’re a little bruised up when we get there.