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.
Recently, the outstanding economist Richard Vedder penned a column in the Wall Street Journal on the problems of higher education in America. He titled it: “College Wouldn’t Cost So Much If Students and Faculty Worked Harder.”
The piece was a preview of his book on the subject, Restoring the Promise: American Higher Education Today to be published May 1. From his summary and from reading his previous writings on the subject, I’m certain the book will be outstanding
His analyses have coincided with my own as a Nevada legislator, higher education regent, college teacher and state controller, and he has brought good data to illustrate issues I have observed in those roles. So, here, I’ll present a summary of his WSJ piece, and in future column I’ll detail from my experience and his book some major issues and solutions to the serious challenges U.S. higher education faces.
Vedder begins: “One reason college is so costly and so little real learning occurs is that college resources are vastly underused. Students don’t study much, professors teach little, few people read most of the obscure papers the professors write, and even the buildings are empty most of the time.”
As a regent and part-time community college instructor for four years, I observed all these phenomena and more first hand. They are some key reasons higher education costs have increased faster in real terms than the incomes of students and their families while those students are being ever more poorly prepared for life and the job market. And taxpayers are shorted.
His first observation is that surveys show college students today spend about 27 hours a week in class and studying, while taking classes only about 32 weeks a year. Or, fewer than 900 hours a year on academics – “less time than a typical eighth-grader and perhaps half the time their parent work to help finance college.”
He notes other researchers have found that in the middle of the 20th Century students spent 50 percent more time – around 40 hours weekly. Grade inflation has vitiated their incentives to work hard because the average grade received has risen from B-/C+ in 1960 to B/B+ now.
Vedder notes that on some campuses students study much more. And, “Engineering majors probably work much harder than communications or gender studies majors.” Ditto, law and medical students. As a sometimes engineering major at Illinois, recipient of a masters from Stanford in Engineering Economic Systems and later law student, I know all that’s not new.
But neither he nor I are suggesting that students responding to the changing incentives is the only problem. Vedder confesses: “I’m part of the problem: I’ve been teaching for 55 years, and I assign far less reading, demand less writing, and give higher grades than I did two generations ago.” Most other professors are less demanding and productive in teaching and useful research than he is, while mostly hard-sciences instructors put in similar teaching and productive research time.
When I taught 15 years ago, I told my community college students at the start of the semester I would teach them just as I would at any four-year college, including the same reading, writing, homework and testing. However, I felt guilty because I succumbed to the grade inflation trend. On the other hand, because a third of them needed remedial English, writing and math skills (having been shorted by their grade and high schools), I provided that service.
Another point he makes is that objective measures show the results of college education today are underwhelming. Similarly, I noted in my controller’s annual reports that American K-12 students’ achievement scores in international tests are in the middle ranks of those for advanced countries, while our per-student spending is among the highest.
A major point I learned as a regent is that much of higher education’s problem is the proliferation of administrative and other non-teaching staff relative to all instructors. Because colleges and universities work hard to cover up this phenomenon, I had trouble getting data on it, and I look forward to his book for more information here.
When we understand the full dimensions of the problem, we can begin crafting remedies. Stay tuned.
The word has spread all over the internet, and all over the news that as many as 50 people conspired in a scheme to help their kids cheat on SAT/ACT tests and / or get their kid admitted to a privileged school on an athletic scholarship - even if the child had never played the sport.
Okay. Well, that’s clearly fraud. You can’t pay someone to take tests for your kid and you can’t get admitted on scholarship for a sport you’ve never played. That’s a crime. And let’s not forget the general idea that the moment you pay for the privilege of placing your child in a college that he/she probably didn’t deserve to be at - you’ve actually significantly harmed someone else who deserved that place but was rejected due to your fraud.
And there are some high profile people involved in this including actress Felicity Huffman (of Desperate Housewives fame) and actress Lori Loughlin (of Full House fame) both who paid huge sums of money to cheat their kids into college. Now, I know parents will do anything for their kids so, to be honest - I’m certainly not surprised to hear that rich parents will, you know - pay large sums of money to give their children even more privilege and more advantages than they already had. This is not a big shock to me.
And this is nothing new, right? I mean, all you have to do is apply common sense and reason to the George W. Bush Yale/Harvard question. How did Bush Jr. get into either ivy league school with his C average in high school, his decent (but certainly not great) SAT score and his zero college sports scholarships? You or I would NOT be able to get into Yale or Harvard with a C average and a decent SAT score. So how did Bush Jr. get in? Well, we all know that answer to that - because his family is well know and rich, rich, rich.
Obviously both schools accepted Bush Jr.., probably for the prestige of the Bush name but maybe, like in these recent cases - out of fraud. It’s very possible the Bush family just shelled out huge sums of cash to both schools until the universities in question said, “Sure, we’ll take your C student son!”
Well, that’s pretty much what this new scandal is all about. And we’re talking all sorts of universities are involved in this - Georgetown, Stanford, Yale, Wake Forest, UCLA, USC, Harvard, to name a few. And officials are claiming this might be just the tip of the iceberg.
So, how did this all happen?
It appears that a man named William "Rick" Singer is the front runner. Singer is CEO of “The Key,” which is a college admission prep company. And Singer pretty much told super rich parents that, for a specific fee, he would pay people to take standardized tests for their kids and then Singer would bribe test administrators to look the other way. If that wasn’t going to work out, he told parents he could create fake sports photos to submit to the schools and pay coaches to recommend a sports scholarships. He did that too! Well, Singer was caught, and he confessed to everything, so I’m not going to bother with the word - alleged.
And, of course, sometimes the parents helped in communications with university officials or coaches. Sometimes they didn’t. But they all paid and they all knew what they were doing was illegal. And some of the parents paid huge amounts of money - up to millions of dollars! I mean, how much does your kid have suck in school for their parents to need to pay millions of dollars to get them accepted?
Anyway, then Singer used his “The Key” business to launder all the money, and all the parents agreed to the scam from top to bottom. And this is pretty much the epitome of fraud, racketeering and conspiracy. So this is going to get a whole lot of rich people in trouble, all their kids are going to get thrown out of their respective schools and lots of money is going to get lost. The lawyers will all make out like bandits, though (but don’t they always).
What will happen now?
Well, will anyone go to jail? Ummmm, probably not any of the parents. They’re all rich and have expensive lawyers. They’ll probably pay a fine or two and get a hand-slap or two. And there will certainly be public embarrassment and humiliation. Prosecutors might pin a few things on some low power scapegoats and throw them in jail as, “a lesson,” but that’s probably all that will happen.
Anyway. I don’t know about you but I am not surprised that super rich people pay ridiculous amount of money to get their kids into a college that they clearly don’t deserve to be in. Is it a crime? Yes. Should their kids be kicked out of school? Yes. Should there be some kind of punishment and/or fine? Yes. Will there be lawsuits? Yes. But, to be honest, the only thing that really shocks me here is that, this time - the rich folks actually have to pay for their crimes. That's actually, pretty surprising.
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.
Student debt has been rising and the average undergraduate doesn’t feel confident they will pay off their loans before middle age.
Lots of factors contribute to the increased debt a student faces. Some of these include:
Higher tuition costs
Increased time requirements to obtain a degree (5 year program vs 4 year)
Fewer students work while taking classes
More competition after graduation
Higher cost of living precludes early repayment of loans
And it is projected to rise. The Congressional Budget Office each year projects the total amount of new federal student loans the office believes they will issue with this year projected to be nearly $1.5 trillion.
Andrew Coates, candidate for University Regent in Southern Nevada, states, “One way that colleges can help students keep their debt under control is by locking-in tuition rates. This means that tuition will not be increased while a student pursues their degree. By locking-in tuition, students will know exactly how much they will pay each year in college, which will help them budget accordingly.”
So how can students curb their debt?
According to US News data, the average cost of tuition and fees for the 2018–2019 school year was $35,676 at private colleges, $9,716 for state residents at public colleges and $21,629 for out-of-state students at state school, with many universities easily exceeding these numbers. So students may want to consider getting early credits completed at community colleges and then finishing their degree at a university. Additionally, many will need to decide if its worth picking an out-of-state college for a degree that provides the same job market edge as an in-state school.
Many students don’t apply for grants, loans and scholarships because of time constraints, misconceptions such as they don’t fit a demographic, or “will be credit history required?”, and lack of optimism that they will even qualify.
Mark Kantrowitz, publisher and vice president of saveforcollege.com states, “More than 2 million students did not get a Federal Pell Grant even though they were eligible because they did not file the FAFSA.” FAFSA (link attached) is a free application for federal student aid assisting students who want to apply for a loan, grant or work study.
Scholarships are ideal in that they do not need to be paid back. Many can be found at scholarships.com.
Many students get a culture shock living on their own when they spend as if Mom or Dad is still footing the bill. If eating out nightly, shopping online, or using excess data does not fit into the amount your trying to live on each month, budget expenses early on and stick to it.
When we try to build our credit as a young adult, we may apply for a credit card that advertises to college students with no monthly fee and “rewards.” However, the interest rates can be up to 25%. If you do use the credit card don’t borrow more than you can pay off each month, always shooting for a zero balance.
Rent, transportation, utilities, meals, entertainment, internet and phone service, add up and can be more costly than tuition. Share expenses with roommates or family members to lessen your loan debt.
Cook and prepare meals for the coming days, use school Wi-Fi, carpool to class, purchase less beer, and use the university gym to save money.
But most importantly, don’t stress about the debt. Your efforts should be concentrated on your schooling and getting a degree is one of the best ways to combat your debt later in life.
If you think the American economy is booming now, just think what it would be like if American collegians had an extra $1.5 billion to spend—especially with President Donald Trump’s tariffs set to raise the prices of imported consumer goods despite he and his administration saying the tariffs won’t result in price hikes.
Well, if prices aren’t increasing, tariffs aren’t working. The point of a tariff is to make locally produced products more attractive to local consumers by raising the price of imported alternatives. This, in theory, would result in more local production and fewer imports. But a tariff is paid by the importer of a product, not the exporter. So the 25-percent tariff Trump recently leveled on Chinese imports is transferred to the American consumers of those goods, not the Chinese producers.
The trade war isn’t taking money out of the pockets of Chinese manufacturers; it’s taking money out of the pockets of American consumers of Chinese products and Chinese consumers of American products. And since the United States runs a $375 billion trade deficit with China, the only way Trump can “win” his trade war is if Chinese economists can’t do the math to match Trump’s tariffs dollar-for-dollar. It’s even becoming more likely trade with China ends altogether. China has already cancelled planned trade talks with Trump.
It is impossible for America to run a trade surplus with China because China produces more products Americans consider essential than America produces for the Chinese, including car, computer and mobile phone components. It’s lower labor costs and Americans’ addiction to consumption allow China to perpetually have the upper hand in a trade war. If an iPhone were made entirely in America, it would cost as much as a brand new car, so while Trump might be making some American-made products more attractive to American consumers, he’s doing so at the expense of American consumers who can’t do without many of the Chinese imports found in their technology and automobiles. Even the Tesla Model 3 can only be 95-percent American-made at most.
Since Americans will be paying more for computers, mobile devices and cars, it’s not entirely unreasonable to forgive the $1.5 billion in student loan debt and allow those accepted into college two years of college education free of charge. Students and parents are going to pay more for the devices required to attend college, and colleges are going to pay more for them as well, which will be reflected in tuition costs, which will further increase student loan debt while decreasing consumers’ available income for spending in the American economy, potentially sinking the stock market.
There are other reasons besides boosting the economy for the government to payoff student loan debt. First, today’s Associate’s degree, usually obtained in two years at a community college, is the equivalent of a 1980s high school diploma. Advances in technology have made working in what is now a global economy much more complicated and necessitates further education be obtained. Students are not leaving high school with the education necessary to provide for themselves let alone a family, and it’s not their fault.
Secondly, with 17 states offering tuition-free college programs, the trend seems to be students at least delaying the accumulation of student loan debt for two years, potentially lowering accrued interest as well as principal loan balances. In short, future college students in the United States will be saddled with considerably less student loan debt than current and past college students. Meanwhile, entire generations (and student loan debt does span generations), are suffering student loan debt and unable to stimulate the American economy by spending money on anything but debt and living expenses.
Finally, the collective credit rating of American college students, past, present and future, would receive a boost that could spur entrepreneurial growth and investment in businesses as a whole. America was the land of opportunity, where you could go from “rags to riches” with enough hard work. America used to be the best place to start a small business and be your own boss. That isn’t the case these days because despite incomes increasing for middle-class Americans, their purchasing power has barely budged since 1965. You can’t grow an economy in which most consumers have hardly more purchasing power than their grandparents did over 50 years ago, and consumer confidence in the stock market can’t increase if consumers have no means to express their confidence by purchasing stocks.
Lifting the $1.5 billion in student loan debt owed by 44.2 million American borrowers would allow 44.2 million Americans to spend their student loan payment, averaging $351 per month, stimulating the American economy instead of simply paying off interest. Lenders can’t be the only ones making money if the American economy is going to grow.
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