Volume 67Number 9

September 2014

THE JOURNAL OF THE SOUTH DAKOTA STATE MEDICAL ASSOCIATION

Volume 67 lNumber 9September 2014

The Journal of the South Dakota State Medical Association

ContentsPresident’s Comments343 Impending Crisis in Health Care in South Dakota – Mary J. Milroy, MD

Alliance News345 Changes in the Medical Alliance? – Catherine Calhoon

Editorial347 2014 Sanford Scholars Day Abstracts – Candace Zeigler, MD; Valeriy Kozmenko, MD;

Matt Bien, MD

The Journal349 Developing an International Clinical Elective for SSOM Seniors – Chaltu Ayano, MSIV350 Increasing Public Access to the Automated External Defibrillator (AED) – Jon Christensen, MSIV351 The Role of Family Involvement in a Nutrition and Physical Activity Education Program:

A Pilot Study – Brad Julius, MS, MSIV

353 Neurobehavioral Screening for Fetal Alcohol Spectrum Disorders in Primary Care – Jordan Makela, MSIV

354 Perceptions of Spirituality and Religion in Medical Care – Chelsea Mann, MSIV355 IHI Open School as the Integrator: An Educational Model for Quality Improvement and

Patient Safety in Health Professions Curricula – Ryan Miller, MSIV

357 Analysis of Blood Donor Motivations – Nathaniel Paulson, MSIV358 Medical Exploration Day: Promoting Early Interest in Health Professions – Joshua Ryan, MSIV359 Fragile X Gene Premutation in an Infertility Clinic – David Somsen, MSIV360 Comparison and Utility of King-Devick and ImPACT Composite Scores in Adolescent

Concussion Patients – B. Joel Tjarks, MSIV

361 Cosmetic Dermatologic Surgical Trianing in U.S. Dermatology Residency Programs: Identifying and Overcoming Barriers – Erin Williams, MSIV

365 Student Perceptions of Their Value to Patient Care – H. Bruce Vogt, MD, FAAFP; Ed Simanton, PhD; Matt Bien, MD, FACP, FAAP; Susan M. Anderson, MD, FAAFP

Primers in Medicine370 Sports Concussion Management: A Review of the Evidence – Mark List, MD,

Mark Vukonich, MD, Wesley Nord, MD; Mark Huntington, MD, PhD

Pharmacology Focus375 Prolonged Paralysis from Non-depolarizing Neuromuscular Blocking Agents:

An Evaluation of Risk Factors – John Kappes, PharmD; Ashley Weber

Special Features377 SDSMA Center for Physician Resources Practice of Medicine Series – The Risks

Associated with Patient Hand-offs

378 SDBMOE Board News – Margaret B. Hansen, PA-C, MPAS379 Quality Focus: QIO Program Changes under the 11th Scope of Work

– Stephan D. Schroeder, MD

380 Patient Education: Update in the ACA – Richard P. Holm, MD381 DAKOTACARE Update: Surviving the Alphabet Soup: Quality Metrics

– Jacque Cole, RN, MS, FNAHQ

382 SDSMA Student Membership Sponsors

Member News383 For Your Benefit: Help Shape the Future of Medicine in South Dakota

2015 SDSMA Meets with Sen. Thune, Rep. Noem During August RecessPublic School Attendance Policies

383 The Issue Is…SDSMA Sends Letter to Gov. Daugaard Outlining State Employee Health Plan ConcernsNew SDSMA Dues Renewal Process for 2015

385 State to Require Yearly Flu Vaccination for its Health Care Workers Don’t Miss the SDSMA Center for Physician Resources Wealth Integration Forums Offered in Sioux Falls and Rapid City!SSOM Medical Student Orientation Week

For the Record387 CME Events

Advertisers In This Issue388 Physician Directory388 Classified Ads

Office of PublicationPO Box 74062600 W. 49th Street, Suite 200Sioux Falls, SD 57117-7406605.336.1965Fax 605.274.3274www.sdsma.org

EditorKeith Hansen, MD

SDSMA PresidentMary J. Milroy, MD

Chief Executive OfficerBarbara A. Smith

SDSMA Vice PresidentMark East, MS

Staff Editor Elizabeth Reiss, MS–ereiss@sdsma.org, 605.336.1965

Advertising RepresentativeElizabeth Reiss, MS–ereiss@sdsma.org, 605.336.1965

South Dakota Medicine(ISSN 0038-3317)Published 12 times per year with one special issue in the spring by the South Dakota State Medical Association.

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Cover photo by Sherrie Bruhn

343September 2014

President’s Comments

Impending Crisis in Health Care in South Dakota By Ma r y J . M i l r o y, MD

SDSMA P r e s i d e n t

The South Dakota State Medical Association(SDSMA) is dedicated to the health of SouthDakotans and advocates for better care of patients.However, there is a crisis on the horizon. South Dakota isfacing a critical shortage of physicians. Physician shortagesof over 45,000 primary care and 46,000 specialty physiciansare predicted by 2020 in the U.S. This is due to an agingpopulation and increased demand for health care due to theAffordable Care Act (ACA). Physicians also are aging, and45 percent of the physicians currently practicing in thisstate are over 50 years of age. Physician shortages are predicted to be most pronounced in rural areas. Currentlymore than one in four South Dakotans live in a primarycare shortage area. The Governor’s Primary Care Task Forceestimated the need to expand South Dakota’s primary careworkforce by 13-17 percent.

The SDSMA continues to work with the Sanford School ofMedicine (SSOM) to provide physicians for the state.Since the expansion to a four-year program in 1974, themedical school has graduated 1,823 physicians; 40 percentremain in South Dakota and 33 percent practice in ruralareas which ranks the highest in the U.S. This summer, 59students entered the first-year class. Next year, thanks tothe support of Gov. Daugaard and the legislature, the classsize will expand by 11 students. In addition, the Frontierand Rural Medicine (FARM) program was launched in thesummer 2014. FARM places six third-year medical studentsin five rural communities. Each student participates inintense nine-month training at one rural community. Thisintroduces the student to rural medicine and fosters interestin practicing in rural communities. The FARM programwill be expanded in future classes. Recently, SSOM DeanMary D. Nettleman, MD, commended the physicians of thestate for their support of the medical school. She noted thatmedical students in South Dakota often face a high debtpost-medical school. This affects both their choice of specialty training and the location of their practice.

South Dakota physicians have been generous with boththeir time and money in support of the students. Since1990, the SDSMA Foundation has provided almost$400,000 in scholarships. This is especially important todayas the average medical student debt has soared to more than$180,000 upon graduation. New this year, the Foundationallocated $250,000 from its general endowment for amatching gift endowment program. Every contribution by adistrict medical society that meets the minimum givinglevel will be matched dollar for dollar through the Foundation.

I would like to thank the Seventh District for participatingin this new opportunity, and I encourage all the districts tochallenge themselves to participate in this important schol-arship program. Contact the SDSMA office prior to Nov. 1to take advantage of this excellent opportunity.

Another crisis facing health care is the increasing lack ofaccess to graduate medical education (GME). While medical schools has increased in numbers and class sizeshave expanded, there have not been a correspondingincrease in the number of residency positions. This year,975 U.S. medical school graduates did not match into grad-uate training positions. Ultimately, 500 were able to enter programs; however, there are still 475 students without programs. This imbalance will only compound the problemin future years as the unmatched numbers grow.

Medicare’s current cap on financial support for GME prevents teaching hospitals from increasing the number ofresidency training positions and often prevents new hospitalsfrom establishing teaching programs. The AmericanMedical Association (AMA) recently expressed support forHR 4282, the Creating Access to Residency Education(CARE) Act of 2014. The CARE Act offers a creative solution to these concerns by establishing federal grants tosupport the creation of new medical residency positions.Importantly, this legislation would target areas with significant need by focusing on states where there are fewmedical residents compared to the general population.Similar legislation, HR1180/S 577, the Resident PhysicianShortage Reduction Act of 2013, seeks to increase GME by3,000 slots each year. South Dakota currently has 225 medical students and only 137 residency training slots. Wemust work together to fund graduate medical school educa-tion to ensure our ability to keep medical students in thestate after they graduate. Among our medical school students who complete their residency in South Dakota, 80percent practice medicine in the state. That is the secondhighest retention rate in the country. The new rural generalsurgery residency program started this summer with six surgical residents, which is a step in the right direction, butwe must continue to advocate for more.

We are fortunate to have a top-ranked medical school inour state. The medical students and residents in SouthDakota are the future providers of our health care. I thankthe South Dakota physicians for their support of the SSOMand encourage all of us to continue to advocate forincreased support for medical education in the state.

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345September 2014

Alliance News

Changes in the Medical Alliance? By C a t h e r i n e C a l h o on

SDSMA A l l i a n c e

The Medical Alliance in South Dakota started morethan 100 years ago. It started as a group of womenwho had similar backgrounds and similar life stressors who wanted to do something collectively to helpthe medical profession and their communities. I would dareto say, with slight differences, such as the addition of malepartners, it is still very much that today.

The South Dakota State Medical Association Alliance hasbeen an active group involved in many projects for theircommunities such as raising money for nursing and medical scholarships, supporting legislation such as lawsrequiring mandatory child seat belts, no smoking in public,and increased taxes on cigarettes. We lobbied to get thefunding for the four-year medical school and lobbied tomaintain the scope of practice for health practitioners inour state.

We continue to support medical students as their costshave risen significantly. We continue to support healthprojects in our districts and in the state; for example, theCribs for Kids project raised over $30,000 the past twoyears. We support candidates for office and the legislativeagenda of the South Dakota State Medical Association(SDSMA).

The National Medical Alliance across the country hasbeen losing members significantly. Our own districts havebeen losing members as well. The book Bowling Alone is along but fascinating book about this phenomenon which isoccurring with all organizations, be they social or political.Many organizations in the U.S. were started in the 1930s,as was ours, and peaked in the 1950s. Most organizationshave lost significant membership in the past 10 years.Hence, the title which indicates that instead of bowling inleagues, now people are bowling alone. The author thengoes on to discuss the impact that organizations have hadupon our society. People from different economic groups,different religious beliefs or different political parties wouldjoin together to meet for some common purpose. In addition to accomplishing the purpose for which they were

founded, they also learned to appreciate others’ points ofview. The author believes that with the breakdown ofthese connections, we have become polarized and lack sensitivity toward others, which he sees as detrimental fordemocracy.

There are many studies about what is currently happeningwithin our society. Families seem to perceive that they areunable to have a comfortable life in most cases without twoincomes. There are many distractions for a family’s limitedtime. There are more organized sports, more outside entertainment and a lot of electronic entertainment. Morefamilies are choosing not to join organizations.

Our organization has currently decided to move away froma formal board structure of president, vice-president, secretary, and treasurer and move to a more informal structure of a “committee of the whole “ for one year witha formal secretary and a formal treasurer to see how that isgoing to work. No one seems to be comfortable with taking on the formal leadership roles due to the large timecommitment. It will only work if all support the informalstructure and volunteer for a project to allow people to participate, but not be overwhelmed by the responsibility.

I believe the Alliance has made a difference to our familiesand the state, and I hope it will continue. This will onlyhappen if people become involved with the various projects and help the Alliance in this re-structuring whichis designed to free up time and yet allow the commitmentsof the past to continue into the future. If you would like tobe involved, call Cathie Calhoon at 605.484.3105 or JulieEvans at 605.431.2389.

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The Scholarship Pathways Program is now in its seventh year at Sanford School of Medicine of theUniversity of South Dakota. It is an elective, student-driven, mentored experience created to promotescholarly excellence in areas of research, education or service; develop leadership skills; and encourage lifelonglearning. Participants are expected to work independently,outside the required curriculum, to design and complete aproject. Eighty students and 70 different mentors have participated in the program thus far, generating more than50 presentations at state, regional, national or internationalmeetings and in more than 50 publications in peer-reviewed journals.

Senior students present their completed projects inabstract, poster format and podium presentations to thefaculty, administration and students at Sanford ScholarsDay. The abstracts from the Sanford Scholars Day 2014 arepresented in this issue. Four students with outstandingprojects were selected to give podium presentations, andtheir projects are highlighted below.

Through his project entitled “Increasing Public Access tothe Automated External Defibrillator (AED),” JonChristensen, with assistance from local fundraising andcommunity awareness, was able to more than double thenumber of non-university, community-based AEDs fromseven to 17 in Vermillion. He also provided CPR trainingto lay rescuers at each location receiving an AED, used theconcept of “sidewalk CPR “ to raise public awareness, andestablished a community AED manager linking new andexisting AEDs to the 911 dispatcher. This project providespotentially lifesaving benefits to citizens of South Dakota.

Ryan Miller’s project, “IHI Open School as the Integrator:An Educational Model for Quality Improvement andPatient Safety in Health Professions Curricula,” was one ofthe first large-scale efforts to measure learning via theInstitute for Healthcare Improvement (IHI). He estab-lished an IHI Open School chapter in South Dakota tobring students, faculty and health care providers together.

The chapter was formed as an interdisciplinary team withover 600 students from eight schools and 13 health disciplines. His abstract reviews the four specific projectfoci the chapter worked to accomplish. This project was amonumental undertaking for a medical student.

B. Joel Tjarks’ project, “Comparison and Utility of King-Devick and ImPACT Composite Scores in AdolescentConcussion Patients,” assessed the efficacy and utility ofthe King-Devick (KD) oculomotor test for use in sidelinediagnosis and monitoring recovery of concussion at sporting events. The KD test, initially developed as a toolto assess saccadic eye movement in children to evaluatereading problems and dyslexia, has unique appeal due to itsease in administration while still providing reliable, objective results. His study found that the KD test appearseffective in objectively monitoring concussion recovery asthe symptoms resolve over several months. This projectcould potentially change the course of concussion manage-ment by health care providers across the state.

Erin Williams’ project, “Cosmetic Dermatologic SurgicalTraining in U.S. Dermatology Residency Programs:Identifying and Overcoming Barriers,” was a cross-sectional,anonymous and voluntary online survey in academic dermatology practices among program directors of U.S.dermatology residency programs. From her study, she concluded that although almost every program provideshands-on cosmetic dermatology training, there are barriersto training, including patient preferences, costs of procedures and products, and program director attitudestoward cosmetic dermatology training. This is an importantand relevant study because procedural competency isimperative for patient safety and quality improvement.

We are pleased with the variety and ingenuity of theScholarship Pathways Program projects and proud of theaccomplishments of the participants. We are honored thatSouth Dakota Medicine once again invited the ScholarshipPathways Program to publish the student abstracts outlining the work that they have done.

347September 2014

Editorial

2014 Sanford Scholars Day AbstractsBy Cand a c e Z e i g l e r , MD ; Va l e r i y K o zmenko , MD ;

a n d Ma t t B i e n , MD

348

349September 2014

Journal

Developing an International Clinical Elective for SSOM Seniors By Cha l t u Ayano , MS IVMen to r : Canda c e Z e i g l e r, MD

Background: International study provides a unique opportunity for U.S. medical students to experience medicinein a diverse and culturally unique environment. As several studies and individual medical student’s experiencedemonstrate, international electives offer students a wide range of diagnostic and communication skills. While inanother country, students have the opportunity to participate in medical care of patients with advanced pathologies while facing the challenges of language and cultural barriers. Many U.S. medical schools offer international clinical electives and/or have a period where a student can participate in an international elective.Currently at Sanford School of Medicine (SSOM), there is no option for such an elective.

Project description: My experience in a hospital in Ethiopia influenced me to focus this project on establishing adesignated international elective for SSOM medical students during their clinical years. Currently, SSOM has noestablished international program of its own. Therefore the aim of this project focused on establishing a reservedfour-week period for an international elective course for SSOM students to take during their fourth year. The experience would allow students to travel for a credited clinical experience at a foreign site already established byanother U.S. medical school or to a site of their choice that meets the objectives outlined by SSOM.

Outcomes: A brief handbook of resources was created for students who may travel for an international elective,including options for an elective at an already established program. This includes a proposal which can be used asa template for a student who is planning to travel to a specific site. I have also prepared an evaluation form uniqueto an international elective, to be used in addition to the current SSOM fourth-year elective evaluation. A courseproposal form was developed for an international elective to be presented to the SSOM medical education committee.

Next steps: Although a formal program is not yet in place, faculty and student interest remains. The documentsprepared through this project will serve to further develop an elective for those interested in international medicine.

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Journal

Increasing Public Access to the Automated External Defibrillator (AED) By J on Ch r i s t en s en , MS IVMen to r : Ro y Mo r t i n s en , MD

Background: Sudden cardiac arrest (SCA) is one of the leading causes of death in the U.S., claiming between250,000 to 500,000 lives a year. A majority of deaths occur outside of the hospital where the survival rates are usually low, ranging from 1 to 5 percent. Defibrillation, applied by an automated external defibrillator (AED), hasbeen recognized as the most important intervention for someone suffering from SCA. In addition, early defibrilla-tion is vital to resuscitation, as research has found that someone in ventricular fibrillation has a 90 percent chanceof survival if defibrillated within the first minute. However, for each minute that passes a person’s chance of survival decreases by 10 percent. Although emergency medical services (EMS) or first responders are able torespond to an incident, lengthy response times may jeopardize a person’s chance of resuscitation. Thus, having anAED in the general vicinity of the incident could dramatically increase an individual’s chance of survival.However, for this to be effective the public must be trained and feel comfortable and confident in use of the AED.

Project description: In order to reduce the call-to-shock time for people suffering from SCA, the concept of public access defibrillation (PAD) endorses an expansion in the traditional role of the AED in the pre-hospital setting by increasing public placement of the AED and training the public in CPR and AED operations. This project’s primary goal was to increase public access to the AED in Vermillion, including schools, churches, the citygolf course and City Hall. Funding was raised to defray cost for locations at higher risk for SCA to obtain an AED.For facilities that already had an AED, information pertaining to that AED’s location was gathered and given tothe 911 dispatch system. The CPR training in the community was improved by coordinating and providing CPRcertification classes to schools, churches and businesses throughout Vermillion. Also, the concept of “sidewalkCPR” was used to raise public awareness.

Outcome:With assistance from local fundraising and community awareness, we were able to improve the numberof non-university, community-based AEDs from seven to 17. Next, CPR training was provided to lay rescuers ateach location receiving an AED in addition to classes for others not involved with those same facilities. The concept of “sidewalk CPR” was used to raise public awareness for “hands-only” CPR and basic AED education.This was done at both university and community-based gatherings. Secondary goals of this project were also completed which included establishing a community AED manager, linking new and existing AEDs with the 911dispatcher, and raising public awareness for SCA and the role of CPR/AED use in such situations.

Conclusion: SCA continues to be a leading contributor to death in the U.S. While early access, early CPR, andearly advanced care all aid in survival, early defibrillation not only appears to be the most crucial link in the chainof survival, it perhaps also offers the greatest area for improvement in pre-hospital SCA. By expanding the traditional role of the AED and increasing its public access in high-risk facilities, one’s chance of survival may bedramatically increased. This service project improved a rural community’s PAD program by increasing public accessto AEDs, providing CPR training, establishing a community AED manager, linking new and existing AEDs to the911 dispatcher, and raising community awareness for SCA and the role of the AED and CPR.

351September 2014

Journal

The Role of Family Involvement in a Nutrition andPhysical Activity Education Program: A Pilot Study By B r a d J u l i u s , MS , MS IVMen to r : M i che l l e Van Be ek , MD

Background: Childhood obesity is associated with many future health complications such as insulin resistance, diabetes mellitus, blood lipid abnormalities, and hypertension. Nationally, 14.8 percent of children aged 2-19 areoverweight and 16.9 percent are obese. In South Dakota, 16.7 percent of children aged 5-19 are overweight and16 percent are obese (32.7 percent combined). Childhood obesity has been shown to be a strong predictor of obesity in adulthood. It has been reported that 69 percent, 83 percent, and 77 percent of obese children 6-10 yearsof age, 10-15 years of age, and 15-18 years of age, respectively, will still be obese at age 25. Systematic reviews havehighlighted the importance of family involvement in childhood obesity interventions; however, few have beencommunity-based or used objective measures to assess physical activity.

Methods: Ten subjects were enrolled in the Let’s Get Moving program, a nutrition and physical activity educationprogram at Brookings Health System in Brookings. Subjects were randomized into either a parent and child groupor a child-only group. Groups were taught separately but received the same education. Height and weight weremeasured and total body dual X-ray absorptiometry was used to measure body composition. To assess ambulatoryactivity, subjects wore a New Lifestyles NL-1000 pedometer for one week. The Family Eating and Activity HabitsQuestionnaire was used to assess four factors that affect obesity in children: activity level, stimulus exposure, eating related to hunger, and eating style. All measurements and questionnaires were completed before and afterthe 10-week program. Groups were compared using student’s t-test and general linear models.

Results: No significant differences were found between groups at baseline except fathers had higher inactivityscores in the parent and child group compared to the child only group (p = 0.04). The child only group had a sig-nificant reduction in total fat mass compared to the parent and child group (p = 0.006) and a near significant reduction in percent fat (p = 0.08). In addition, the child only group had a near significant reduction in BMI compared to an increase in the parent and child group (p = 0.06). Mothers in the parent and child group showedsignificant reductions in factors related to inactivity compared to those in the child only ( p = 0.005). In addition,fathers in the parent and child group had significant reductions in factors related to stimulus exposure comparedto those in the child only group (p = 0.006). No other significant differences between groups were noted.

Conclusions: Family involvement did not result in any significant improvements in body composition or ambulatory activity. However, the parent and child group did show greater improvements in lifestyle factors relat-ed to obesity compared to the child only group. Consequently, family involvement may encourage lifestyle changesin children that over time result in improvements in body composition and subsequent disease risk reduction.

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353September 2014

Journal

Neurobehavioral Screening for Fetal AlcoholSpectrum Disorders in Primary Care By J o r d an Make l a , MS IVMen to r : Amy J . E l l i o t t , PhD

Background: The constellation of the effects of intrauterine alcohol exposure is described by the term fetal alcohol spectrum disorders (FASD) and includes facial dysmorphology, growth restriction, and behavioral disorders. Fetal alcohol syndrome, one of the diagnoses within FASD, is the leading cause of preventable mentalretardation and birth defects, and is a problem that spans social and economic classes. There have been studieswhich show that early intervention for children with FASD results in more positive behavioral outcomes.However, early treatment is dependent on early diagnosis. This project began with the goal of evaluating whichneurological signs and symptoms were used by physicians in the diagnosis of FASD, comparing age at diagnosis.

Project description:We designed a single-institution retrospective chart review of patients evaluated for FASD inSouth Dakota. Information that pertained to the neurobehavioral characteristics of the patients was collected inorder to determine what parameters were used by practitioners in the diagnosis of FASD. The records evaluatedwere split into three groups based on age at evaluation, 0-47 months, 48-96 months, and greater than 96 months.

Outcomes: The results of the chart review showed that children under 4 years old were less likely to be diagnosedafter evaluation than children 4-8 years or over those over 8 years (32.4 percent, 52.6 percent, and 48.9 percent,respectively). There was an increased co-incidence of diagnosed attention deficit disorder with increased age atdiagnosis (42.9 percent, 60 percent, and 81.8 percent). The most common co-morbid conditions among those evaluated for FASD were attention disorders and oppositional defiant disorder. Caregivers of patients frequentlymentioned “impulsivity” and difficulty understanding the consequences of actions during the evaluation.

An important qualitative outcome made through the review of hundreds of charts is that a diagnosis within thefetal alcohol spectrum is only made after significant functional psychological testing, a thorough medical exam, andwith a history suggestive of maternal alcohol ingestion. This is a task that is clearly beyond the scope of most ruralcare facilities that may be staffed by a single primary care or mid-level provider. Because of the proven benefit ofearly intervention, it is clear that there needs to be a simple yet systematic screening tool for rural providers to useto refer potential patients to the multidisciplinary FASD clinics in more urban centers.

Conclusions: One challenge in the diagnosis of FASD in South Dakota is the geographical distance to the multidisciplinary clinics for many patients. This means that an important role of the rural primary care physicianwill be to identify and refer appropriate patients to tertiary centers for evaluation. To aid in this endeavor,researchers have developed a brief questionnaire from the Child Behavior Checklist (CBCL). The CBCL is a stan-dardized questionnaire given to parents/caregivers designed to assess behavior problems. The full form test contains120 questions, but researchers followed trends from years of evaluating children for FASD to develop a 10-questionsurvey to quickly screen likely FASD cases with a sensitivity of 86 percent and specificity of 82 percent.

Journal

354

Perceptions of Spirituality and Religion in Medical Care By Che l s e a Mann , MS IVMen to r : M i cha e l McVay, MD

Background: A majority of patients and physicians consider spirituality and religion relevant to clinical practice;however, few individuals have discussed spiritual matters in a medical setting. Patient spirituality and religion influence decision-making processes, coping mechanisms, and individual understanding of disease. The purpose ofthis study is to expound upon previous research by surveying South Dakota physicians about their perception ofthe importance of spirituality in medicine, incorporation of spirituality into their own medical practice, and perceived barriers to integrating spirituality into medicine.

Methods: A questionnaire was developed using the templates of previous research on spirituality in medicine. Itsurveyed physician demographics (gender, age, specialty, and practice location) and individual spirituality (personaldenomination and perceived level of spirituality/religiousness), as well as the physician’s incorporation of spirituality into clinical practice. Integration of religion in medicine was investigated through questions about frequency of performing a spiritual history, praying with patients, and discussing religious issues with patients. Inaddition, physicians were asked about their personal perception of importance, pertinence, and comfort regardingreligious aspects of interactions with patients.

Results: Physicians from southeastern South Dakota (N=176) responded to this questionnaire. Of these participants, 72 percent identified as male, 64 percent identified as practicing in an urban location (defined as apopulation greater than 50,000), and 68 percent identified as specialists (not family medicine, pediatrics, or general internal medicine). Respondents primarily characterized themselves as Christian (47 percent Protestant,30 percent Catholic, and 9 percent other Christian), with a smaller contingency (less than 5 percent of each)describing themselves as Agnostic, Atheist, Hindu, Jewish, Mormon or Muslim. Among family physicians, 21 percent routinely inquire about religious affiliations of new patients and 68 percent inquire in the situation of ahealth crisis; whereas among non-family physicians 9 percent routinely inquire about religious affiliations of newpatients and 53 percent inquire in the situation of a health crisis. The most common reasons for incorporating spirituality into medicine are the beliefs that spirituality and religion provide a support system for patients (82 percent), positively affect health (76 percent), improve health care outcomes (64 percent), and enhance the therapeutic relationship (52 percent). Major barriers to incorporation of spirituality among those physicians surveyed include lack of adequate training (33 percent), fear of alienating the patient (28 percent), personal discomfort (25 percent), and time constraints (21 percent).

Conclusions: Though South Dakota physicians tend to view themselves as very or moderately spiritual and believethat spirituality and religion positively affect the health of their patients, few routinely engage patients in conversations about these issues. Family physicians are more likely to discuss these subjects with their patients thanother primary care physicians or specialists, and all physicians are more inclined to have these conversations in thecase of a health crisis or life-threatening illness. Barriers to these dialogs include personal discomfort, time constraints, fear of alienating patients, and lack of adequate training.

355September 2014

Journal

IHI Open School as the Integrator: An EducationalModel for Quality Improvement and Patient Safety in Health Professions Curricula By Ry an M i l l e r, MS IVMen to r : Wende l l Ho f fman , MD FACP

Background: Since the 1999 Institute of Medicine report, “To Err is Human,” which demonstrated that approximately 98,000 die each year in the U.S. from preventable medical errors, safety and quality have been givena central focus in health systems. More than ever, a change in culture is needed within the entire health care community. To this aim, the Institute for Healthcare Improvement (IHI) Open School (OS) has become a driving force, serving to accelerate the incorporation of patient safety (PS), quality improvement (QI), teamwork,and communication science into medical education, “…fill[ing] the current gap in the professional preparation ofimprovement leaders…” Since its establishment in 2008, over 650 schools around the world have established OSchapters and over 170,000 students have registered. Many schools have begun implementing PS and QI with someusing IHI OS courses as core content. However, no evidence or models regarding the best utilization of IHI OS andits online courses currently exist.

Methods:An IHI OS chapter was established in South Dakota to bring students, faculty, and health care providerstogether at a time when only a handful of chapters had integrated courses into formal curricula. By design, thechapter approached 21st century health care as an interdisciplinary team with over 600 students from eight schoolsand 13 health disciplines. In addition to hosting chapter events, four specific project foci included 1) An interdis-ciplinary pilot project introducing PS and QI into existing first year curricula using OS courses, 2) Sessions forthird-year medical students to assess OS courses in the context of faculty-facilitated small groups, 3) Developmentof a longitudinal quality and safety curriculum, and 4) Integration of OS courses across South Dakota health professions schools. Measures included quantitative data collection with pre- and post-surveys using five-pointLikert scale as well as qualitative data analysis.

Results: In the 110-student interdisciplinary pilot project, medical students and allied health students demonstratedsignificant learning in 16 of 16 and 13 of 16 (p=0.05) primary teaching points related to OS course objectivesrespectively. The “First Do No Harm” sessions showed that third-year medical students preferred the addition offaculty-facilitated case studies, and students agreed that PS and QI topics are important to learn prior to residencytraining. Based on the previous results, a student-designed longitudinal PS and QI curriculum was implemented.The curriculum incorporated an introductory lecture with “Partnering to Heal” session, 10 OS courses with small-group discussion, and a scholarly project. Additionally, the establishment of a “Deans Forum” collaborative led tothe incorporation of IHI OS courses as core curricula in four South Dakota colleges and eight health disciplinesthus far.

Conclusions: Our work was one of the first large-scale efforts to measure learning via the IHI OS and provides anexample for the novel use of an OS chapter. We created a model where the chapter itself was at the nexus of curricular innovation and organizationed student events, whereby it developed and provided the structure to maintain curricula as well as a forum for students to gather. Importantly, the model contributes to national effortstoward enhancing interprofessional education. Results suggested that OS courses are efficacious as a didactic corein teaching the science of quality, safety, teamwork, and communication and that faculty-led small group discussion may add to the learning. Furthermore, the longitudinal SSOM Quality and Safety curriculum serves asan attempt to use evidence to develop curricula using IHI OS. Finally, the international IHI Open School networkprovides a vector for spread of this and other innovative curricular models.

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357September 2014

Journal

Analysis of Blood Donor Motivations By Na than i e l P au l s on , MS IVMen to r : P e t e Tr a v e r s , MD

Background: Blood and blood products are essential in the treatment for a wide range of conditions and in patientsof all ages. The primary source for blood products in the U.S. derives from volunteer donors. Thus, donor recruitment and donor retention are vital factors for a blood bank to maintain an adequate supply. Despite theirefforts, nearly all blood banks have experienced acute shortages. Developing a better understanding of donors’motivations to donate would allow for a more robust supply of blood to be available.

Methods: Individuals ages 18-36 were approached to participate in the study when they registered for their donation appointment. Those willing to participate answered a 13-question multiple-choice survey during theirdonation. Surveys were collected from 897 participants between July 2011 and October 2011. SAS software wasused for statistical analysis. Univariate analysis was done using Fisher’s exact test. A multivariate model was constructed controlling for age and marital status and including the variables that were significant in univariateanalysis. Subgroup analysis was done comparing first-time donors versus previous donors as well as those responding on the survey “highly likely” to return versus “neutral/unlikely” to return.

Results: No individual motivating or inhibiting factor reached statistical significance. Based on likelihood ofreturn the variables recognition, frequency, number of previous donations, and length of time since previous donation were significantly different (p-values

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Medical Exploration Day: Promoting Early Interest in Health Professions By J o shu a Ry an , MS IVMen to r : H . B r u c e Vog t , MD

Background: As high school students begin to consider where they want to further their education and careers,they will likely have many questions about the path and reward of becoming a healthcare professional. There aremany great careers in the health professions, but many high school students are unaware of all the opportunitiesavailable. One avenue to encourage these students to consider the healthcare fields is to expose them to currenthealth professions students in a friendly atmosphere. With this in mind, the medical exploration day was createdto allow high school students the ability to interact with health profession students and have their questionsanswered.

Development: The initial plan for this project was to create an informal day for high school students to hear aboutthe process of getting into medical school. Three small “boot camps” were conducted during the summers of 2011and 2012, with four to eight students present at each camp. The day consisted of a PowerPoint presentation, a tourof Sanford USD medical center, and a Q&A session with family medicine residents. Feedback was positive, butmany students were interested in learning about health careers other than being a physician. After the first twosummers, it was felt a new approach was needed to reach more students and make the camp more exciting. Holdinga camp in the winter months allowed high school teachers and counselors to bring their students during the schoolday. The decision was also made to offer the opportunity for hands on experience in the Parry Center for ClinicalSkills and Simulation. Finally, it was felt that including students from multiple health professions would create amore informative day for the high school students.

Design: The medical exploration day was divided into three distinct one-hour experiences: a tour of Sanford USDMedical Center, a health professions student panel, and an interactive Parry Center experience. The tour involvedareas of Sanford USD Medical Center, including labor and delivery and the emergency department. The healthprofessions student panel included medical, physician assistant, physical therapy, nursing and occupational therapy students. The Parry Center experience included CPR demonstration, heart and lung auscultation, ultra-sound, surgical knot tying and intubation techniques. The students were split into three groups, and they rotatedevery hour between the three settings. Following the group rotations, students were provided a pizza lunch.

Outcomes: The first medical exploration day was held in February of 2013. Over 50 students from multiple schoolsand towns around Sioux Falls attended. The general feedback from the students and teachers was positive. A second medical exploration day was held in February of 2014 with over 50 students present. It was again considered to be an enjoyable day from both the high school students and health professions students. It was apparent that the students enjoyed being able to ask questions of the panel members, and to hear that if they arecommitted to reaching a goal, they will have a great chance of being successful. With the success of the first twomedical exploration days, the plan is to keep these events happening on a yearly basis. A brochure has been created that will help guide interested medical students in organizing these events. As each year passes, a new groupof medical students will have the chance to coordinate these events. The ultimate success of the project would befor these events to be ongoing and conducted by health professions students who were once participants themselvesin medical exploration days.

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Fragile X Gene Premutation in an Infertility Clinic By Dav i d Soms en , MS IVMen to r : Ti f f a n y Von Wa l d , MD ; and Ke i t h Han s en , MD

Background: Fragile X syndrome is the most common form of inherited mental retardation. It is an X-linked disorder associated with the gene FMR1. This gene, in recent years, has been found to be associated with two otherconditions: tremor-ataxia syndrome and primary ovarian insufficiency (POI). The latter of these two has beenheavily studied recently, and a correlation between the number of CGG repeats within the untranslated 5’ sectionof the FMR1 gene and the severity of ovarian failure has been elucidated.

With the recent addition of FMR1 screening to common prenatal carrier screening panels, we are learning moreabout the FMR1 gene as well as the clinical picture of FMR1 premutation carriers. On routine screening of patientsin the Sanford reproductive endocrinology clinic, a higher than normal proportion of intermediate CGG (~45-54)repeat carriers was found. Considering proper prenatal counseling of these patients is important, we wanted to seeif patients with this premutation had higher rates of premature ovarian failure than controls.

Methods: A retrospective case control study was performed via electronic medical record chart review. We controlled for age, race, and ethnicity. Markers of ovarian function including anti-mullerian hormone (AMH),three-day follicle stimulating hormone (FSH), and antral follicle count (AFH) were studied. We also looked atfamily history of developmental delay, personal history of surgery or chemotherapy, smoking status, and weight asthese factors have all been known to affect ovarian function.

Results: Four patients were found to have copy numbers of 45, meeting the ACMG’s definition of “intermediate”carriers. Sixty-nine controls were evaluated, and 13 were removed from the study for lack of ovarian reserve markers.

Statistical significance could not be achieved due to low power, but some interesting trends were noted. Most striking of all was the correlation of our data with current literature showing that patients in the “intermediate”range had markers of ovarian reserve suggesting diminished ovarian reserve (higher FSH, lower AMH, and lowerAFC) on average.

Conclusions: Though our sample size is not large, our results do show a correlation between FMR1 CGG repeatnumber and ovarian dysfunction. This data adds to the ongoing debate regarding repeat number and its implications on female reproduction.

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Comparison and Utility of King-Devick and ImPACTComposite Scores in Adolescent Concussion Patients By B . J o e l T j a r k s , MS IVMen to r : Ve r l e D . Va l en t i n e , MD FACSM

Background: Concussion in sport has garnered significant clinical and public concern and media attention, particularly over the last few years. A recent study by the Centers for Disease Control and Prevention(CDC) indicated that in individuals younger than age 19, sports-related concussion accounts for approximately 170,000emergency department (ED) visits every year. It is estimated that a certain degree of oculomotor dysfunction ispresent in 65-90 percent of patients who have experienced some form of traumatic brain injury. Objective, validated and field-expedient measurements of visual-motor deficit which potentially affect and are related to cognitive visual performance are not well-recognized and utilized by health care providers. The King-Devick (KD)oculomotor test is a relatively new and innovative oculomotor test that has been recommended and utilized forsideline diagnosis of concussion. KD was initially developed as a tool to assess saccadic eye movement in childrento evaluate reading problems and dyslexia. This study examined the utility of the KD test by comparing KD longitudinal data with post-concussion symptom scale (PCSS) measures and the four composite scores from thewidely used ImPACT test in recently concussed patients.

Methods: Thirty-five concussed individuals were recruited through a local sports medicine clinic. During each of four clinical visits, each subject participated in a number of post-concussion assessments, including PCSS evaluation, KD test and ImPACT. Means and standard deviations for each variable at each visit were computedafter inspection of data for unusual values. Mixed-model repeated measures ANOVA was used to evaluate statistical significance.

Results: KD times and PCSS scores progressively decreased over the course of four visits. Three of the ImPACTcomposite scores increased over the four visits while reaction time progressively decreased. These findings wereconsistent with the notion that the participants were progressively recovering from their brain injuries, across theperiod of the study. All correlations between ImPACT composite scores (as well as symptoms) and KD results indicated parallel improvement — that is, as ImPACT composite scores improved and symptoms resolved, weobserved faster KD times. All correlations were significant, with P values less than 0.0001 in all cases.

Conclusions: Improvements in ImPACT and KD performance paralleled each other during the period of concussion recovery. Specific to our hypothesis, ImPACT composite scores were shown to be significantly correlated to the KD test times. The KD test appears effective in objectively monitoring concussion recovery andsymptom resolution over several months. The unique appeal of the KD test lies in the rapid, easy manner in whichit is administered while still providing reliable, objective results. This can help health care providers make the mostinformed decisions regarding return to activity and academic norm.

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Cosmetic Dermatologic Surgical Training in U.S.Dermatology Residency Programs: Identifying andOvercoming Barriers By E r i n Wi l l i am s , MS IVMen to r : S a r ah S a r b a ck e r

Importance: The public and other medical specialties expect dermatologists who offer cosmetic dermatology services to provide competent care. There are numerous barriers to achieving cosmetic dermatology competencyduring residency. Many dermatology residents enter the workforce planning to provide cosmetic services. If a training gap exists, this may adversely affect patient safety.

Objectives: To identify resources available for hands-on cosmetic dermatology training in U.S. dermatology residency training programs and to assess program director (PD) attitudes toward cosmetic dermatology trainingduring residency and strategies, including discounted pricing, used by training programs to overcome barriers related to resident-performed cosmetic dermatology procedures.

Design, setting, and participants: A cross-sectional, anonymous, and voluntary online survey in academic dermatology practices among PDs of U.S. dermatology residency programs.

Main outcomes and measures: Frequency of cosmetic dermatology devices and injectables used for dermatologyresident hands-on cosmetic dermatology training, categorizing PD attitudes toward cosmetic dermatology trainingduring residency and describing residency-related discounted pricing models.

Results: Responses from PDs were received from 53 of 114 (46 percent) U.S. dermatology residency programs. Allbut three programs (94 percent) offered hands-on cosmetic dermatology training using botulinum toxin, and 47 of53 (89 percent) provided training with hyaluronic acid fillers. Pulsed dye lasers represented the most common laseruse experienced by residents (41 of 52 [79 percent]), followed by Q-switched Nd:YAG (30 of 52 [58 percent]).Discounted procedures were offered by 32 of 53 (60 percent) programs, with botulinum toxin (30 of 32 [94 percent]) and fillers (27 of 32 [84 percent]) most prevalent and with vascular lasers (17 of 32 [53 percent]) andhair removal lasers (12 of 32 [38 percent]) less common. Various discounting methods were used. Only 20 of 53 (38 percent) PDs believed that cosmetic dermatology should be a necessary aspect of residency training; 14 of52 (27 percent) PDs thought that residents should not be required to perform any cosmetic dermatology procedures.

Conclusions and relevance: Although almost every program provides hands-on cosmetic dermatology training,there are barriers to training, including patient preferences, costs of procedures and products, and PD attitudestoward cosmetic dermatology training. To promote patient safety, procedural competency is imperative.

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BackgroundEngagement in meaningful activities has been studied invarious populations in occupational therapy and identifiedas a key conecpt.1-2 Such activities must align with one'sgoals, provide evidence of competence, and demonstratevalue to the team or social group.1 Similarly, the recentCarnegie report on educating physicians lists meaningfulcontribution as integral to professional identity formation.Cooke et al. state that “forging of a professional identity, orformation, is both a process of personal development and asocial enterprise, a process of becoming and contributing.”3

Yet, there is little research in medical education regardingstudents and meaningful activities or perceived value. Alimited number of papers have looked at how patients viewthe role of medical students.4-6 None have focused on themedical student’s perspective.

This study sought to further define meaningful activitiesand value to patient care as perceived by third- and-fourthyear students at the University of South Dakota Sanford

School of Medicine (SSOM). It explored two questionsrelated to medical student experiences in their clinicalyears: 1) Do students consider the activities in which theyparticipate meaningful? and 2) Are there differencesbetween students in the third year compared to students inthe fourth year of medical school? It also investigatedwhether there was any correlation between perceived outcomes and a sense of accomplishment.

MethodsStudents were surveyed in the third and fourth year ofmedical school using the Engagement in MeaningfulActivities Survey, a brief but multi-faceted tool to assessmeaningful activity.1 This instrument has been previouslyvalidated in a diverse sample including young adults in auniversity setting.2 Surveys were forwarded electronicallyto third- and fourth-year students in March of the 2012-2013 academic year. Third-year students were asked torespond to the survey based on their most recent clerkshipexperience. Fourth-year students were asked to base their

Student Perceptions of Their Value to Patient Care By H . B ruce Vog t , MD, FAAFP ; Ed S iman ton , PhD ;

Ma t t B i en , MD, FACP, FAAP; and Su s an M. Ande r son , MD, FAAFP

AbstractPurpose: Engagement in meaningful activities is integral to professional identity formation, yet little has beenreported in the medical education literature and no studies have focused on the medical student’s perspective. Thisstudy sought to further define meaningful activities and value to patient care as perceived by third- and fourth-yearmedical students and to explore whether there was correlation with a sense of accomplishment.

Methods: The authors surveyed third- and fourth-year medical students of the University of South Dakota SanfordSchool of Medicine regarding their perceptions using the Engagement in Meaningful Activities Survey. Responsesof the two groups were compared, and correlations between perceived outcomes and a sense of accomplishmentwere calculated.

Results: Both third- and fourth-year medical students perceived themselves to be of value to patients and attending physicians and of help to patients, attending physicians, and the patient care team, although in all casesthe mean responses for fourth-year students trended higher. The correlation between these items and a sense ofaccomplishment was greater among fourth year students.

Conclusion: Student perceptions of their value to the patient and patient care team begin to play a more prominent role as clinical experiences progress in parallel with their identify formation as physicians.

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responses on their four-week, rural family medicine clerk-ship (a required fourth-year rotation at SSOM).

Students rated their perception of outcomes using a 5-point Likert scale (5=strongly agree, 4=agree, 3=neutral,2=disagree, 1=strongly disagree). Response rate for third-year (n=39) and fourth-year (n=40) students was 74 percent and 77 percent, respectively. Mean responses werecalculated for all survey items for both groups. For each student group, correlation coefficients were calculated todetermine strength of association between a perceived outcome and a “sense of accomplishment.” The study wasapproved by the University of South Dakota InstitutionalReview Board.

ResultsThe survey’s first six items studied student perception oftheir contribution to patient care. Mean ratings above 3.0for all items indicated that most students in the third andfourth years “strongly agree” or “agree” that they both helpand are valued by patients, the team, and their attendingphysicians (Figure 1). Comparison of the two groupsshowed a trend toward fourth-year students perceivingthemselves of greater help and value for all items, reachingstatistical significance for valued by patients (p = 0.003)and valued by the patient care team (p = 0.015).

Compared to fourth-year students, third-year studentsrated increased competence from their clinical experienceshigher (p = 0.008). Despite this difference, increased competence was the second highest rated outcome forfourth-year students (mean = 4.179), minimally lower thantheir perception of value to patients (mean = 4.205).

Though the rating for sense of accomplishment from theirclinical experiences was higher among third-year comparedto fourth-year students, the difference was not statisticallysignificant (p = 0.213). While sense of accomplishmentwas rated higher than any of the patient care items bythird-year students, fourth-year students rated sense ofaccomplishment lower than any of the patient care items.

To determine a possible association with a sense of accomplishment, correlation coefficients were calculatedbetween sense of accomplishment and the other items. Asshown in Figure 2, correlation coefficients indicated astronger association between perceived outcomes andsense of accomplishment for fourth-year compared tothird-year students. All correlations were statistically significant (p < 0.05), except for third-year students andtheir perceived value to the patient care team.

DiscussionEngagement in meaningful activities, a concept consideredkey in occupational therapy, remains essentially unstudiedin medical education. This study compared third-year andfourth-year medical students regarding their perceived helpand value to patients, attending physicians and thepatient-care team and explored if there were correlationsbetween these items and a sense of accomplishment.

Both third- and fourth-year medical students perceivedthemselves to be of “value” to patients and attendingphysicians and of “help” to patients, attending physicians,and the patient care team. Although less than a majority(46.1 percent) of third-year students strongly agreed oragreed with the statement that they perceived themselves

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Figure 1. Perceived Outcomes of Activities Figure 2. Correlation of Outcomes with “Sense of Accomplishment”

y axis = Mean (Likert Scale: 5 = Strongly Agree; 4 = Agree; 3 = Neutral; 2 = Disagree; 1 = Strongly Disagree)*Statistically significant (p value < 0.05).

y axis = Correlation Coefficient

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to be of “value to the patient care team,” none of the students disagreed with the statement and 53.8 percentindicated a neutral opinion. That is, all students expresseda neutral or positive view when assessing their perceived“value to the patient care team.” In all cases, however,responses trended higher for fourth-year students (greaterthan 71 percent “strongly agree” or “agree” on all items),reaching statistical significance for perceived “value” topatients and the patient care team (p = 0.003 and 0.015,respectively).

In this study, both third- (87.1 percent) and fourth-year(69.3 percent) students indicated that their respectiveclerkships gave them a sense of accomplishment. Third-year students rated “becoming more competent” fromclerkship experiences higher than fourth-year students.The correlations between perceived outcomes and sense ofaccomplishment were stronger among fourth-year students(Figure 2); however, all correlations were statistically significant (p < 0.05) except for third-year students andtheir perceived value to the patient care team.

As students progress through medical school, they developprofessional identity as a physician. Perceived value to thepatient and patient care team is an important aspect of thatidentity formation. It is understandable and expected thatthird-year students perceive learning and gaining compe-tence as an important outcome early in clinical training.At some point, however, students begin to shift or at leastbalance “becoming more competent” with “value” topatient care. Furthermore, the findings of this study suggesta correlation between student perception of value inpatient care and a sense of accomplishment. We believethis correlation reflects professional identification withbecoming a physician.

This study has potential limitations. First, student numbersare relatively small and represent a single institution.Second, the setting for clinical training varied – third-yearstudents were primarily based in an urban location, whilefourth year students completed the survey after a ruralmedicine clerkship. Students in the rural setting may havebeen incorporated into the team more readily, possiblyeven out of necessity. Finally, third-year students were surveyed regarding their most recent clerkship. It is possible that perceptions as to their help or value may havediffered following other individual third-year clerkships.

This study confirms the need for future research.Upcoming changes in the SSOM curriculum will allowcomparison of both third- and fourth-year students in a

rural setting. Traditional block clerkships will also be compared to longitudinal integrated clerkships.

In conclusion, this study helps to further define meaningfulactivities and perceived value to patient care in medicalstudents during their clinical years. Students in both thethird and fourth year consider clinical activities meaningful.However, as clinical experience progresses in parallel withidentity formation, value to the patient and patient careteam begins to play a more prominent role.

REFERENCES

About the Authors:H. Bruce Vgt, MD, FAAFP, Former Chair and Professor Emeritus, Department of FamilyMedicine, University of South Dakota Sanford School of Medicine, USD Health ScienceCenter.Ed Simanton, PhD, Assistant Professor, Department of Family Medicine and Director ofEvaluation and Assessment, Office of Medical Education, University of South DakotaSanford School of Medicine, USD Health Science Center.Matt Bien, MD, FACP, FAAP, Associate Professor, Departments of Internal Medicine,Pediatrics and Family Medicine, University of South Dakota Sanford School ofMedicine; Avera Medical Group Brookings.Susan M. Anderson, MD, FAAFP, Associate Professor and Chair, Department of FamilyMedicine, University of South Dakota Sanford School of Medicine, USD Health ScienceCenter.

Please note: Due to limited space, we are unable to list all references. You may contact South Dakota Medicine at 605.336.1965 for a complete listing.

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IntroductionConcussions, a subset of mild traumatic brain injuries(TBI), are common sports-related conditions encounteredin both rural and urban family medicine outpatient clinicsand emergency rooms across the country. They representfunctional rather than structural damage to the adolescentbrain. Although not as potentially lethal as head injuriesresulting in structural damage, concussions are not inconsequential.

Recent public controversy has enhanced awareness of headinjuries, creating increased concern about their diagnosisand appropriate management. Popular media has broughtthe topic into the national spotlight in the form of numerous television programs, investigative newspaperand online stories, and documentaries, most notably the2013 PBS Frontline, “League of Denial: The NFL’sConcussion Crisis” which brought awareness of sports-related concussions to the homes of millions of Americans.Estimates place incidence of sports-related concussions in

the U.S. at around 1.6 to 3.8 million.1

The short-term deficits from concussions and otheruncomplicated mild TBI cause significant decline in ability to effectively work, go to school, or participate insporting events, creating an increasing public health concern. The result of multiple concussions may be deficitswhich are cumulative and permanent. Even if handledappropriately, this disease of temporary consequence cansometimes have long-term problems that cause significantmorbidity. Recent years have brought a paradigm shift inthe way concussions and mild TBI are managed. Primarycare physicians are on the forefront of diagnosis and treatment of TBI in athletes and need to be aware of recentchanges in concussion management. In this article wereview the evidence supporting the recent change inguidelines for management of the concussed patient.When applicable, we present the level of evidence usingthe Strength of Recommendation Taxonomy system(Figure 1).2

Sports Concussion Management: A Review of the Evidence By Mark L i s t , MD; Ma rk Vukon i ch , MD; Wes l e y No rd , MD;

and Mark Hunt ing ton , MD PhD

Primers in Medicine

AbstractBackground: Concussions, a subset of mild traumatic brain injuries (TBI), are common sports-related conditions.Public controversy has aided to the awareness of these head injuries, creating increased concern about their diagnosis and appropriate management. Recent guidelines have brought a change in the way concussions are managed.

Methods:We reviewed recent literature on recognizing and managing concussions and other mild, uncomplicatedTBI. While randomized controlled studies and well-designed observational trials were preferred, due to the paucity of methodologically sound evidence, relevant systematic reviews, retrospective reviews and observationaltrials were also included.

Results: Evidenced-base management of concussions, specifically with cognitive and physical rest, is sparse, andthe majority of the evidence that does exist is poor. We identified several studies that may contradict the recentguidelines that full physical and cognitive rest is the most beneficial management strategy.

Discussion:Recent guidelines in post-concussion management and return-to-play are valuable tools to the primarycare physician. However, they have not been validated and are not the result of large scale trials showing demonstrable benefit. While the guidelines are useful tools for returning athletes to full activity following an injury,post-concussion management should be individualized based on each patient assessment, symptoms, and responseto care.

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MethodsThe medical literature was searched electronically usingPubMed. We reviewed the most recent findings on recognizing and managing head injuries including, but notlimited to, concussions and other mild, uncomplicatedTBI. All citations were reviewed by two investigators.

Exclusion criteria were applied at abstract and full-textreview stages to identify appropriate studies to be used inthe evidence-based review the subject. Abstract-only studies were excluded based on inability to access pertinentstatistics, methods, or other information making theabstract information incomplete. We excluded studies ofsevere or complicated (structural) TBI as this was outsidethe scope of this article. The attempt was made to findstudies whose results were relevant to the primary carephysician and their patients.

While randomized controlled trials and well-designedobservational studies were preferred, due to the paucity ofmethodologically sound evidence, relevant systematicreviews, retrospective chart reviews and smaller observa-tional trials were also collected and analyzed for relevanceto the topic.

ResultsClinical Presentation and Natural CourseConcussions can be caused by any force either directly tothe head, neck, face, or indirectly to another body part thattransfers its force to the brain. Sudden movement of skullon its vertebral axis produces injury with concussions, andthe types of injuries include coup-contrecoup, rotational,acceleration, or deceleration forces.3,4

Although management of concussions has changed, theclinical features remain the same. Each individual concussion is different and results in a graded set of clinicalsymptoms. These symptoms range from mild confusion andamnesia, headache and dizziness of varied severity, nauseaor vomiting, and may or may not involve loss of conscious-ness. Other clinical findings include vacant stare, slowedverbal response, inattention, loss of orientation, disjointed

or incomprehensible speech, incoordination, memorydeficits, emotional lability and irritability.

Resolution of the clinical and cognitive symptoms typicallyoccurs within seven to 10 days for 80-90 percent ofpatients. However, it is important to note that in somecases symptoms may be prolonged for months.4 Post-concussion symptoms can be similar to those experiencedduring the acute concussion period, and include headache,dizziness, imbalance, nausea and vomiting, visual distur-bances, light and noise sensitivity, irritability, attention problems, depression, sleep disturbances, and fatigue. Whilemost of these are mild, temporary and manageable symptoms, sometimes post-concussive courses can be morecomplicated. A 2008 systematic review of 3,289 TBI casesshowed that overall, 51.5 percent of patients developedchronic pain (typically cephalgia) following TBI; thosewith minor TBI – typical of sports-related concussion –developed a higher rate of chronic pain than those withsevere TBI (75 percent vs. 32 percent).5

DiagnosisWhether the physician is on the sidelines of the footballgame where a player has been concussed, in the emergencydepartment evaluating the young patient involved in amotor vehicle accident, or in the outpatient clinic the dayafter a middle aged worker presents with an occupationalinjury, the workup of a TBI begins with a thorough historyand examination, assuming the patient’s mental status isamenable for answering questions appropriately. Afterassuring the patient is stable and has no serious spineinjury, has no life threatening injuries, or emergent medicalneeds, the physician should begin to assess timing, mechanism, and immediate symptoms following the injuryincluding but not limited to loss of consciousness and lossof memory of the event before or after the injury.

Typically, concussion symptoms indicate a functional disturbance and by definition should have no abnormalityon neuroimaging. Advanced imaging such as CT scan isnot recommended unless concern for intracranial hemor-rhage is suspected or the possibility of structural injury isindicated by clinic decision rules (SORT = C). Indicationsfor imaging that are potentially relevant to sports-relatedinjury include advanced age greater than 60 years, GlasgowComa Score of less than 13 immediately after injury or lessthan 15 after two hours, persistent vomiting, signs of a basilar skull fracture, suspected skull fracture, posttraumaticseizure, drug or alcohol intoxication complicating posttrau-matic evaluation, or fall from height greater than 3 feet.6

Sideline neuropsychological testing may be helpful toidentify cognitive deficits; evidence that there is benefit tocompleting a baseline test to compare acute changes

Figure 1. Strength of Recommendation Taxonomy (SORT)

A Consistent, good-quality patient-oriented evidence

B Inconsistent or limited-quality patient-oriented evidence

C Consensus, disease-oriented evidence, usual practice, expert opinion, or case series for studies of diagnosis,

treatment, prevention, or screening

post-injury is lacking.7,8 Neither evidence nor consensusexists on one test being more appropriate than another, but several recommendations suggest using SCAT3, SAC,BESS, or similar sideline tests to assess the degree of cogni-tive deficit present following the injury (SORT = C).4,7,9

There is no evidence that neuropsychological testingchanges prognosis or outcomes, but may be a useful tool toguide return to play management (SORT = C).

ManagementManagement of concussions is where the majority ofchanges have occurred in the past several years. Limiteddata is available specifically on the management of sports-related concussion. Even when expanding to all causes ofhead injury, evidence for management of concussions andother minor TBI with cognitive and physical rest is sparse;the majority of the information that does exist is poor.Moser, et al. demonstrated in a small study of 49 pediatricconcussion patients that cognitive and physical rest for oneweek did improve symptoms and cognitive performanceregardless of how long after the initial concussion the restwas initiated, but was not compared to control during theepisodes.10 Conversely, a retrospective chart review demonstrated that aggressive cognitive and physical activity after concussions in pediatric patients increasesymptoms and worsen cognitive testing. This analysis alsoshowed that patients who performed light school work andhome activity actually were better off in performance andsymptoms than those with lower levels of activity, signaling that perhaps full cognitive and physical rest following concussion is not the most appropriate manage-ment for all patients.11 One study based on 107 patientswith mild TBI did show initial full bed rest to be associatedwith less severe post-concussion symptoms at two week follow up; however, only dizziness was statistically signifi-cant from the control group.12 Applying this latter study to

athletes with concussion is difficult, since it was not indicated in the study methods whether patients hadabnormalities on neuroimaging studies, thus classifyingtheir injury as a non-concussion TBI.

Initial acute management of head injury in athletes shouldbe individually based upon the mechanism and severity ofinjury, ruling out more severe TBI, securing the patient’sairway, and following acute trauma protocols as needed(SORT = C).7 When concussion is suspected, the athleteshould be removed from play and evaluated by a licensedprofessional trained in concussion care (SORT = C).7

Sideline tests such as those mentioned above can then aidin diagnosis (SORT = C).7

According to the expert recommendations made at the2012 Zurich Conference on Concussion Management, ifthe diagnosis is made by a physician at a sporting event:

1. An assessment of the concussive injury should be madeusing the SCAT3 or other sideline assessment tools.

2. The player should not be left alone after the injury, andserial monitoring for deterioration is essential over theinitial few hours after injury.

3. A player with a diagnosed concussion should not beallowed to return to play on the day of injury.4

The American Medical Society for Sports Medicine’s(AMSSM) concussion in sport position statement echoesthese recommendations (SORT = C), with the further recommendation of formal medical follow-up for any athlete with concussion (SORT = C).7 The South DakotaLegislature codifies this medical follow-up as mandatory,and requires written return-to-play clearance.13

Computerized – and non-computerized – neuropsycholog-ical evaluation can be an important component of

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No activitySymptom limited physical and cognitive rest.

Light aerobic exercises

Sport-specific exercises

Non-contact training drills

Full-contact practice

Figure 2. Stepwise return-to-play.

Advance on average one step per day as tolerated; if any post-concussive symptoms occur, drop back to the prior asymptomatic

step for 24 hours before attempting to progress again.

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REFERENCES1. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of trau-

matic brain injury: A brief overview. J Head Trauma Rehabil. 2006;21(5):375-8.2. Ebell MH, Siwek J, Weiss BD, Woolf SH, Susman J, Ewigman B, et al. Strength

of recommendation taxonomy (SORT): A patient-centered approach to gradingevidence in the medical literature. Am Fam Physician. 2004;69(3):548-56.

evaluation of an athlete with concussion and a part of thereturn-to-play protocol. Combined with symptom evaluation, neuropsychological evaluation was able to predict protracted recover with a sensitivity of 65 percentand a specificity of 80 percent (compared to 47 percent and77 percent with symptom evaluation alone and 53 percentand 75 percent with neuropsychological evaluationalone).14 AMSSM recommends that the majority of concussions are appropriately managed without neuropsy-chological testing. Testing is an adjunct to clinical assessment and judgment and not to be used in isolation; itmay be of added value in the setting of the high-risk athletes (SORT = C).7

Medication use for symptomatic relief after the acute period (up to 10 hours) may be considered, but should bedone so with care (SORT = C).7

The Zurich Conference recommends return to play shouldbe individually initiated for each athlete in a step-wisefashion (Figure 2). If the patient is able to tolerateadvancement through the steps with no return of symptoms, they may return to play. Using a step wiseapproach, the overwhelming majority of athletes should besymptom free at seven to 10 weeks. (SORT = C).4

A significant risk of premature return to play is “secondimpact syndrome.” When a second head injury occurs priorto complete resolution of the symptoms of the first concus-sion, there appears to be an increased risk for cerebraledema which may be lethal; more minor impacts can havemore severe consequences.7 It is critical not to rush returnto play (SORT = C).

Most concussions resolve in one to two weeks; however, insome cases a post-concussion syndrome develops in whichsymptoms persist for a long period of time and may includepermanent cognitive impairment and chronic traumaticencephalopathy. The mechanism of this, and optimal management for it, remain elusive.7,9

DiscussionConcussions are a common sports injuries faced by all primary care physicians and the push for correct diagnosisand appropriate management has been intensified in thepast few years due to the increased awareness of theseinjuries in the general public. Many recent changes havebeen made to the management of mild head injuries,including a push for increased cognitive and physical restfollowing the initial phase following the injury. However,return-to-play guidelines have not been validated and arenot the result of trials showing demonstrable benefit.

Much of what we know about concussion and other headinjuries is not necessarily generalizable to sports injuries.The mechanisms of injury and forces involved may be

quite different than those encountered on the playing field,and the majority of studies involve adults rather than adolescents. While the guidelines are useful tools forreturning athletes to full activity following an injury, post-concussion management should be individualized based oneach patient’s assessment, symptoms, and response to care.

About the Authors:Mark List, MD, Sioux Falls Family Medicine Residency Program; Department of FamilyMedicine, University of South Dakota Sanford School of Medicine.

Mark Vukonich, MD, Sioux Falls Family Medicine Residency Program; Department ofFamily Medicine, University of South Dakota Sanford School of Medicine.

Wesley Nord, MD, Sioux Falls Family Medicine Residency Program; Department ofFamily Medicine, University of South Dakota Sanford School of Medicine.

Mark Huntington, MD PhD, Sioux Falls Family Medicine Residency Program, Center forFamily Medicine; Department of Family Medicine, University of South Dakota SanfordSchool of Medicine.

Please note: Due to limited space, we are unable to list all references. You may contact South Dakota Medicine at 605.336.1965 for a complete listing.

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Neuromuscular blocking agents (NMBA) are occasionally used as continuous infusions in theintensive care unit for improving ventilator compliance. However, over the last decade a few trialsfound potential benefits with early (i.e., within 48 hours ofdiagnosis) and short (less than 48 hour infusions) adminis-tration of cisatracurium in acute respiratory distress syndrome (ARDS).1-3 The most recent trial showed a hazard ratio for death of 0.68 (95 percent CI, 0.48 to 0.98;P=0.04).3 When cisatracurium was used as adjunctive therapy in prone positioning a hazard ratio for death of0.44 (95 percent CI, 0.29-0.67;P

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corticosteroids observed a clear association with myopathyand average time spent paralyzed. Myopathy developed in6 percent of patients paralyzed for less than 24 hours, 38percent of patients paralyzed for 24 to 48 hours, and 85 percent of patients paralyzed for more than 48 hours.6

Selection of NMBA for ARDS treatment can be debated;however, trials showing mortality benefit for this indication utilized cisatracurium. Evaluation of the differences between aminosteroid compounds (i.e., pancuronium, rocuronium, and vecuronium) and benzylisoquinolinium compounds (i.e., atracurium,cisatracurium, mivacurium, and doxacurium) causing prolonged paralysis may help with selection. Unfortunatelythere is limited information addressing this issue.Aminosteroid compounds demonstrate prolonged recoveryrisk in prospective cohort, prospective randomized single-blind and double blind trials.10 The only link of benzylisoquinolinium compounds to acute myopathy iscase reports with concomitant corticosteroids for at leastsix days. However, one cohort study found the incidence ofmyopathy was similar for atracurium compared to pancuronium or vecuronium.6

With a slight resurgence of NMBAs for ARDS, practition-ers should be cognizant of the adverse effects. Increase risk

of developing prolonged paralysis or myopathies is associatedwith accumulation of the parent compound or its metabo-lites, concomitant administration of corticosteroids, andduration of paralysis. Based on the number of reports it isalso possible aminosteroid compounds have a higher riskthan benzylisoquinolinium compounds. However, thisassociation may be due to past practice in which aminosteroid compounds were more commonly prescribed.

REFERENCES1. Gainnier M, Roch A, Forel JM, Thirion X, Arnal JM, Donati S, Papazian L: Effect of

neuromuscular blocking agents on gas exchange in patients presenting withacute respiratory distress syndrome. Crit Care Med. 2004;32:113–119.

2. Forel JM, Roch A, Marin V, Michelet P, Demory D, Blache JL, Perrin G, GainnierM, Bongrand P, Papazian L: Neuromuscular blocking agents decrease inflammato-ry response in patients presenting with acute respiratory distress syndrome. Crit Care Med. 2006;34:2749–2757.

3. Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, et al.Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363:1107–1116.

4. Guerin C, Reignier J, Richard J, Beuret P, Gacouin A, Boulain T, et al. PronePositioning in Severe Acute Respiratory Distress Syndrome. N Engl J Med.2013;368:2159-2168.

About the Author:John Kappes, PharmD, Assistant Professor, South Dakota State University College ofPharmacy; Clinical Pharmacist, Rapid City Regional Hospital.

Ashley Weber, PharmD candidate 2015.

Please note: Due to limited space, we are unable to list all references. You may contact South Dakota Medicine at 605.336.1965 for a complete listing.

Pharmacology Focus

377September 2014

A “hand off” is the transfer of responsibility for patient carefrom one health care professional to another. Hand offs occurat shift change with the attending physician, hospitalist orspecialist, between floor nurses, with other facilities, and withthe patient at discharge.

The most dangerous point during a patient’s emergencydepartment (ED) visit is the hand off. According to the JointCommission Center for Transforming Healthcare, an estimat-ed 80 percent of serious medical errors involve breakdowns incommunication at hand off. In a study of closed malpracticeclaims, 24 percent of missed diagnoses in the ED were relatedto inadequate hand offs.

During hand offs, the health care professional’s normal atten-tiveness may be relaxed because the patient has already beenassessed, or because the parties involved may have opposingpurposes — perhaps the departing physician or nurse wants towrap things up and go home, while the incoming physician ornurse wants to clear the “board” or list of patients being seen.

Using ineffective and nonstandard communication methodsis an identified root cause of patient injury during hand offs.Studies of communication failures at hand off identify twomajor categories of failure: 1. Content omissions, identified as the failure to communi-

cate critical information needed to care for a patient,either verbally or in writing; and

2. Failure prone communication processes, such as illegible,unclear or untimely communication.

Researchers have identified these common barriers to effective hand offs in the ED: • Signal-to-noise ratio – The noisy, chaotic ED environmentcan make communication difficult.

• Conciseness versus completeness – with limited time forcommunicating, the quality of the hand off often dependson available time instead of patient condition.

• No standard approach – The content, location, style andlength of hand offs is usually inconsistent and based on personal preference.

• Ambiguous moment of transition of care – After the handoff has occurred, the departing physician or nurse will some-times remain in the ED to complete documentation.Confusion can arise if patient care questions are directed tothe departing provider.

• No clear high-risk triggers for dangerous hand-offs – Thereis little research information available to help physiciansidentify potentially high risk hand off situations. These situations may include an uncertain diagnosis, an unstablepatient, an unclear disposition, a consultant driven evaluation, a pending imaging study, deviations from a

typical diagnosis or treatment plan, a patient with a psychiatric illness or a prolonged stay in the ED.

• Cognitive bias – The receiving physician in the hand offusually relies on the departing physician’s diagnostic skilland accuracy. Erroneous initial diagnoses can be perpetuatedin hand off situations.

• Economic construct of the ED – Productivity based compensation models for physicians can discourage thorough hand offs.

How to improve: • Limit distractions and environmental noise when handing off; • Allow more time or establish a method for question and answer;• Standardize communication through the use of processessuch as SBAR (situation, background, assessment and recommendation) and standard hand off templates;

• Include patient specific information on hand off templates(either paper or electronic) such as main complaint, currentcondition, recent changes in condition, medications, treatment, test results, pending test results, anticipatoryguidance and next steps;

• Develop and