A Needs Assessment Pilot Study of Patients with High Utilization in an Academic Inpatient Setting


Alexander S. Roseman, M.D.1*, Hannah Thompson, M.D.1, Audrey Jiang, BS1, Lisa Obasi, BA1, Andrew M. Pattock, BS1, Jamie P. Schlarbaum, BS1, Daniel R. Wells, BS1, Andrew P.J. Olson, M.D.2,3

Author Affiliations:

1University of Minnesota Medical School, Minneapolis, MN, USA
2Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
3Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA

Full Text Article PDF

*Corresponding Author: Alexander S. Roseman; alexander.rosemanMD@baystatehealth.org

Key Words: needs assessment; high utilization; super utilizers; high utilizers; academic medical centers


Background: A disproportionate amount of health care spending in the United States is attributed to a small subset of patients who employ inpatient and emergency department (ED) services. While patients with high ED utilization have previously been well- described, patients seen in an inpatient academic medical setting may differ with regard to demographics, medical conditions, and social factors.

Objectives: We aimed to characterize patients with high utilization in an academic inpatient setting for the purpose of identifying unmet needs.

Setting and Patients: Adults aged 18–80 were eligible for inclusion if they had more than three admissions to a general medicine service of an academic medical center within a large health care system. Patients who were admitted for pregnancy, oncology, trauma, or surgical procedures for acute conditions or were diagnosed with dementia or encephalopathy were excluded. Twenty-six patients met inclusion/exclusion criteria and were approached to be interviewed, of which 13 agreed to be interviewed. Measurements: Face-to-face administration of a self-reported survey assessing unmet needs regarding services for medical or mental health needs, access to health care, housing, transportation, or legal services, and any other barriers to health the respondent identified.

Results: All of those surveyed had health insurance and regular visits with primary care providers (mean 14 visits per 12 months). The most prevalent medical conditions identified were depression (85%) and chronic pain (77%). In addition, patients self-identified having an average of 2.2 chronic conditions. Financial struggles were common as 62% of the respondents reported annual incomes of <$12,000, and 77% were unemployed over the previous 12 months.

Conclusion: These results indicate unique clinical and social characteristics associated with high readmission rates at one academic medical center, suggesting the need for additional patient-centered research of this population to aid in the development of novel strategies to reduce over-utilization and improve health.

Published: Spring, 2019


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Expert Opinions on Healthcare for Immigrants in Norway


Andrea Kubicki1, Haben Debessai1, Megan Masten1, Reena Pullukat1, Kirsten Salmela1

Author Affiliations:

1College of Human Medicine, Michigan State University, East Lansing, MI, USA

Full Text Article PDF

*Corresponding Author: Megan Masten; mastenme@msu.edu

Key Words: Norway; healthcare; immigrant; barriers to care; language


Background: Documented immigrants eligible to stay in Norway for more than 6 months can enroll in the universal healthcare system for full healthcare services, such as acute, chronic, and preventative care.1 All other non-citizens only have access to emergency services. With an increasing influx of immigrants to Norway, it is advantageous to evaluate the Norwegian healthcare system, how documented and undocumented immigrants utilize the system, and any barriers they may face when doing so. The aim of this study is to identify barriers to healthcare for immigrants in Norway in order to better address them in the future.

Methods: Sixteen subjects with knowledge of immigrant healthcare in Norway were interviewed. Participants were asked the same standardized four questions; answers were audio-recorded, transcribed, and analyzed.

Results: Major themes that emerged included the following: (1) universal access is a benefit once accepted into the system, (2) timeliness is an issue, (3) chronic disease and mental health are common immigrant-specific health issues, and (4) language and lack of cultural competency are major barriers to care.

Conclusion: There is a need for improved translation services and cultural competency as the immigrant population in Norway increases.

Published: Spring, 2019


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7. Abebe DS. Public health challenges of immigrants in Norway: a research review. NAKMI Report 2010; 2.

8. Eli K, Ytrehus S. Barriers to health care access among undocumented migrant women in Norway. Soc Health Vulnerability 2015; 6(1): 28668.

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Ioannidis E, et al. Good practice in health care for migrants: views and experiences of care professionals in 16 European countries. BMC Public Health 2011; 11(1): 187.

12. Jensen NK, Nielsen SS, Krasnik A. Expert opinion on best practices “in the delivery of healthcare services to immigrants in Denmark”. Dan Med Bull 2011; 57(8): A4170.

13. Mladovsky P. Migrant health in the EU. Eurohealth London 2007; 13(1): 9.

14. Wachtler C, Brorsson A, Troein M. Meeting and treating cultural difference in primary care: a qualitative interview study. Fam Pract 2005; 23(1): 111–15.

Opioid Safety Education in Adolescent Students


Alexandra K. Feiertag, B.A.1*, Catherine A. Martin, M.D.1,2, Gregory E. Guenthner, M.L.I.S.2

Author Affiliations:

1College of Medicine, University of Kentucky, Lexington, KY, USA
2Department of Psychiatry, University of Kentucky, Lexington, KY, USA

Full Text Article PDF

*Corresponding Author: Alexandra K. Feiertag; alex.feiertag@uky.edu

Key Words: opioid; overdose; safety; education; adolescent


Purpose: Opioid overdoses profoundly impact thousands of families across the United States. Behind this issue lies the accessibility of opioid prescriptions right inside our medicine cabinets. Our goal was to educate adolescent students in Kentucky schools about this matter because they comprise a vulnerable population.

Methods: Pre- and posttestings were used to analyze 26 adolescents’ knowledge, attitudes, and awareness regarding opioid overdoses pre- and post-intervention.

Results: Adolescents displayed significantly improved results from pre-test to post-test. Overdose Knowledge scores improved by 16% from pre- to post-intervention (p = 0.01). Attitude to Act scores improved by 35% (p = 0.03). Drug Disposal Awareness scores improved by 54% (p < 0.01).

Conclusions: This study demonstrates that education improves adolescents’ opioid overdose knowledge, attitudes, and awareness. The evidence shows that there are educational gaps that should be filled by teaching adolescents about the opioid epidemic and providing them with resources.

Published: Spring, 2019


1. Overdose death rates. National Institute on Drug Abuse. August 2018. Available from: https://www.drugabuse.gov/ related-topics/trends-statistics/overdose-death-rates [cited 10 August 2018].
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3. Curtin SC, Tejada-Vera B, Warner M. Drug overdose deaths among adolescents aged 15–19 in the United States: 1999– 2015. Centers for Disease Control and Prevention. August 16, 2017; Available from: https://www.cdc.gov/nchs/products/ databriefs/db282.htm [cited 10 August 2018].
4. Slavova S, Bunn TL, Gao W. Drug overdose deaths in Kentucky, 2000–2013. Kentucky Injury Prevention and Research Center. March 6, 2015; Available from: http:// www.mc.uky.edu/kiprc/projects/ddmarpdak/pdf/ KyDrugOverdoseDeaths-2000-2013.pdf [cited 10 August 2018].
5. Seth P, Rudd RA, Noonan RK, Haegerich TM. Quantifying the epidemic of prescription opioid overdose deaths. Am J Public Health 2018; 108(4): 500–2. doi: 10.2105/ AJPH.2017.304265
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7. Whiteside LK, Walton MA, Bohnert ASB, Blow FC, Bonar EE, Ehrlich P, et al. Nonmedical prescription opioid and sedative use among adolescents in the emergency department. Pediatrics 2013; 132(5): 825–32. doi: 10.1542/peds.2013-0721 8. Frank D, Mateu-Gelabert P, Guarino H, Bennett A, Wendel T, Jessell L, et al. High risk and little knowledge: overdose experiences and knowledge among young adult nonmedical prescription opioid users. Int J Drug Policy 2015; 26(1): 84–91. doi: 10.1016/j.drugpo.2014.07.013
9. Tilley JC, Ingram V. 2016 overdose fatality report. Kentucky Office of Drug Control Policy. 2016. Available from: https:// odcp.ky.gov/Documents/2016%20ODCP%20Overdose%20 Fatality%20Report%20Final.pdf [cited 10 August 2018].

MSRJ 2019 Cover Art Competition

The Medical Student Research Journal is hosting its first cover art competition! This is a competition to have your art featured in the Fall 2019 edition of the Medical Student Research Journal. This is a great opportunity to showcase humanism in medicine and earn a CITATION that you can add to your curriculum vitae!


• Competition Dates?  June 1 to August 31, 2019
• Theme?  Medicine
• Who is eligible?  All MSU graduate and undergraduate students, KCAD students.
• How to compete? Please submit artwork in PDF or JPEG format by 11:59pm, August 31 2019.

Please send submissions to:

Check out the official flyer and last years cover art below:

Fall 2018 publication cover

Volume 6: Fall 2018 Issue

The Fall 2018 Issue (click for PDF) is finally here! A big thank you to our authors, and especially to our Junior and Senior student editors who made this edition possible:

Francesca Cazzulino MS4, Larissa Georgeon MS4, Marten Hawkins MS4, Mariam Khan MS4, Jessica Martín MS4, Rohit Nallani MS4, Monica Pomaville M.D., Caitlin McCarthy MS3, Genevieve Pourzan MS3,  Aiden Tan MS5, Sara Rosenblum MS4, Amina Ramadan MS3, Kathleen Louis MS3, Kyle Hildebrandt MS4, Alex Chavez-Yenter M.D., Kevin Lutley M.D., Amanda Witte M.D., and Nadine Talia M.D.

*If you would like a print copy of the Fall 2018 edition, please inquire via email @: contact@msrj.org


by Andrew Albert

Layers of dirt, rock and bone,
dark, damp, days of carefully peeling off one by one with a fine-tooth comb.
Focus, hope, patience, needed to defend against anticipation.
The agitation can become overwhelming in the mine, I’ve seen it happen ore’ again.

When digging too deep without repose
this awakens the earth, protecting what is trying to be exposed.
One can put their whole being into this purpose, scars and ache to tell.
Know well that under dirt, rock and bone there may be gold.

Folding layers of hardship and worn nerve can hide a soul.
Life like gold.
Just as the treasures of the earth are hidden.

Let then, the miner and physician know,
that below the surface there is true color to show.
For how much more precious is a life than metal?
We must persist in uncovering the layers.



Poem Commentary

The central theme of this poem was to describe the persistence required of physicians when working with patients that may be difficult to understand, and how that could connect to the process of gold mining. They both share a persistence in the act of uncovering, whether uncovering a precious metal in mining, or removing individual barriers to get to know a patient (alternative: person). Structurally the poem includes two lines of true rhyming followed by two lines of dissidence to build tension. Every new paragraph begins with an early connecting rhyme to attempt to bring relief to the previous paragraph’s tension. This echoes the fact that the physician’s process of uncovering is an ebb and flow of tension and resolve. The poem was designed to end without a resolve with a reference to the title. This was meant to prompt the reader to look inward, contemplate the theme as a whole and connect the weight of how much time and effort should be invested in people. It may be difficult to appreciate the complete meaning throughout the lines, so this next section is meant to address some of those nuances.

Lines 1-4: The poem begins with a vague reference to mining that may be unfamiliar to most. In placer mining, many days are spent in machinery peeling back the earth, slowly descending towards the layers in which gold can be found. This mystery to which the poem is initially referring, was meant to draw the reader in and promote a moment of wonder. The type of wonder that is defined as “a moment of admiration, caused by something unexpected, unfamiliar, or inexplicable.” This wonder and curiosity can be the same way students and physicians may feel initiating a connection with a new patient. Line 3 describes how gold mining can feel like an endless process. You may find yourself asking, “Will this be worth it; are we going to find gold? What does it even look like”? The anticipation is unbearable, and one needs a strong sense of hope and vision to keep going. The same concept must be applied to patients. It may be easy to give up on someone, and believe there is nothing worth digging for. Sometimes all you want to do is give up, and the anticipation and waiting can seem overwhelming, but hope helps you persist.

Lines 5-8: Mining can be a dangerous process. If you are not careful with maintaining the angle of repose (defined as, “the steepest angle at which a sloping surface formed of a particular loose material is stable.”) when excavating the earth, the walls can cave in. Mistakes like this happen when the miner gets impatient or greedy. Just like the earth can protect its precious metals, so too patients cover themselves and hide if “rubbed” the wrong way. The process requires great care and patience, but if done in a careful manner there may be a reward at the end.

Lines 9-11: The next section reveals and confirms the connection between gold mining and humanity, with layers of hardship being the experiences that may need to be uncovered to find what is beneath. The gold in humanity is not meant to be a specific human trait, but rather the unique good in each individual. Also, a fascinating characteristic about gold is that every piece is highly unique in color and shape, and you do not need to be an expert to find a piece of it in an inconceivably large mess of dirt. You always know when you see it.

Lines 12-15: The last section alludes to “true colors.” This makes an important distinction of neutrality because what is revealed may in fact not be beautiful or precious, but they are true colors none the less. Sometimes, even after the long hours, days, and years of trying to uncover this treasure, there may not be any gold at the end of your pursuit. It is a sad truth, but both the miner and the physician must continue on in hope regardless. In regard to the line “life more precious than metal,” one must consider how vigorously we seek and sacrifice for our worldly desires, and question whether we ought to give an even more significant effort in caring for our patients.

“What I hope the reader takes from this poem is that people and situations can be complex and difficult to work with, but one must persist in hope of finding the value in a person. Physicians, after all, are just like miners, and despite major setbacks, wall cave ins, bankruptcy, or hardship, they will be back to continue digging with a renewed vigor and hope for treasure.”


The author is currently in his fourth year of medical school. Prior to committing to a career in medicine he worked for six summer seasons, gold mining in the Alaska Range.


Publication DOI: 10.15404/msrj/10.2018.0159
Corresponding author: Andrew Albert
Contact: drewalbert7@gmail.com
College of Human Medicine, Michigan State University, East Lansing, MI, USA

MSRJ 2018-2019 Editorial Staff

2018-2019 MSRJ Editorial Staff

Visit another recent post to meet our Executive Editorial Board: http://msrj.chm.msu.edu/2018-2019-msrj-executive-editorial-board/

Senior Editors

Olivia Hudson- Olivia is a 4th year medical student serving as Senior Editor for the MSRJ. She is originally from Okemos, MI. She studied Human Biology at Michigan State University and played club lacrosse prior to medical school. She is interested in pursuing a career Interventional Cardiology. In her spare time, she enjoys biking, cooking and competitive sports.

James Parkkonen is a 4th year medical student serving as Senior Editor for the MSRJ. He hails from Negaunee, MI and majored in Psychology and Criminal Justice at the University of Michigan. He is a future Emergency Medicine physician whose hobbies include basketball, sitcoms, reading and kittens.

Aidan Tan is a 5th year medical student studying at the University of New South Wales and serving as a Senior Editor for the MSRJ.

Daniel Havlichek- Dan is a 4th year student at MSU-CHM serving MSRJ as a senior editor. He is an alumnus of the University of Michigan with a degree in microbiology. Career interests include Gastroenterology and general internal medicine. He is still seeking the perfect chicken tikka masala recipe.

Meghan Hill – Meghan is a 4th year medical student serving as Senior Editor for MSRJ. She is from Caledon, Ontario and received her Bachelors in Pharmacology at McGill University in Montreal, Quebec prior to starting medical school at MSU CHM. She is pursuing a career in Internal Medicine with potential specialization in Pulmonology and Critical Care.

Larissa Georgeon is a 4th year medical student at Michigan State University College of Human Medicine. She received her B.A. in Biology from Clark University and her M.P.H. in Epidemiology from Texas A&M University. Prior to medical school, she was an Epidemiological Fellow at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. She is interested in Global Health and has gained international experience through her public health internship in Mumbai, India and volunteering at a rural clinic in Surin, Thailand. Her passion is to pursue a career in women’s health and help alleviate domestic and global health disparities.

Francesca Cazzulino is a 4th year medical student serving as a Senior Editor for MSRJ. She is from Pasadena, CA and received her Bachelors of the Arts in Biology from Oberlin College and a Masters in Public Health in Epidemiology from UCLA Fielding School of Public Health. She is interested in pursuing a career in Internal Medicine.

Junior Editors

Maria Rich – Maria is a 2nd year medical student at Michigan State University College of Human Medicine. She grew up in Grand Rapids, Michigan and received her B.A. in Biology from Kalamazoo College where she enjoyed studying abroad in Quito, Ecuador and playing varsity soccer. Prior to starting medical school, she worked as a Clinical Research Coordinator with the BeatCC Pediatric Oncology Research Team. At this point in her medical education, she is excited about pediatrics, genetics, and palliative care.

Ninette Musili – Ninette is a 2nd year medical student at Michigan State College of Human Medicine. She grew up in Ann Arbor, Michigan and attended the University of Michigan for a Bachelor of Science in Biomolecular Science. She is strongly interested in Global Health disparities and how they affect women and children healthcare. At this point in her education she has a strong interest in Surgery and Obstetrics/Gynecology.

Mutinta Chisowa- Mutinta is a 3rd year medical student Michigan State University College of Human Medicine. She grew up in Kalamazoo, Michigan and attended Oakwood University and recieved a B.S in Biology. She is interested in pursuing Emergency Medicine.

Baiju Patel – Baiju is a 3rd year medical student at Michigan State University College of Human Medicine. I grew up in Macomb, Michigan after arriving from India when I was a child. Attended Wayne State University and received BA in Biology. At this point in my education I have an interest to various fields ranging from Pediatrics, Psych, Neuro and Emergency Medicine.

Maddie Hulse – Maddie is a 3rd year medical student at Michigan State University College of Human Medicine. She grew up in East Lansing, Michigan and attended the University of Michigan and received a BS in Molecular and Cellular Biology. She is interested in pursuing a career in Internal Medicine or Family Medicine.

Emma Herrman – Emma is a 3rd year medical student at Michigan State University College of Human Medicine. She grew up in Shelby Twp,. MI and attended the University of Michigan, receiving a BS in biomolecular science with a minor in sociocultural anthropology. She is unsure what area of medicine she wants to pursue at this point, but is interested in emergency medicine, pediatrics and heme/onc.

Caitlin McCarthy – Caitlin is a 3rd year medical student at Michigan State University College of Human Medicine. She received her Bachelor of Arts in Chemistry and Psychology in 2013 from Kalamazoo College. After college graduation, she taught high school chemistry at University Prep High School in Detroit for three years. Outside of medical school, Caitlin is a registered yoga teacher and teaches vinyasa weekly at a studio in Grand Rapids. Her professional interests include preventive health, public and community health, women’s health, and education. She hopes to ultimately go into a field of medicine that affords her opportunities in advocacy, continuity of care, and meaningful relationships with patients.

Megan Kechner – Megan is a 3rd year medical student at Michigan State University College of Human Medicine. She received her Bachelor of Science in Neuroscience and Psychology in 2015 from Michigan State University. Her past research experience includes the study of molecular mechanisms underlying neuropsychiatric disorders such as depression and addiction. She has also conducted research at Vanderbilt University exploring the genetic variation in the human dopamine transporter gene and its role in Attention Deficit Hyperactivity Disorder. At CHM, Megan is currently using a pre- and post-test model to assess outcomes of the ThinkFirst injury prevention program. She is spending her clinical years in Flint, MI and is in the Medical Partners in Public Health Certificate program. Her professional interests include injury prevention, mental health, public health, and academic medicine. Ultimately, she is interested in pursuing a career in pediatrics, PM&R, or neurology.

Danielle Sethi – Danielle is a 3rd year medical student at Michigan State University College of Human Medicine. She received her Bachelor of Science in Architecture in 2012 from University of Michigan and her Master of Science in Physiology and Biophysics in 2014 from Georgetown University. After graduate school, she helped implement and manage the scribe program at the University of Michigan. She is in Flint, MI for her clinical years and she is in the Public Health Certificate program. Her professional interests include women’s health, public health, infectious diseases, and global medicine. She is interested in pursuing a career in Surgery or Emergency Medicine.

Advance Directive Status in >65yo ED Population

Advance Directive Status in the Greater Than 65-Year-Old Emergency Department Population

Author: Kelsey Grace , Michelle Carson MD, August Grace, David Betten MD

Author Affiliations: Sparrow Hospital Department of Emergency Medicine

[button link=”http://msrj.chm.msu.edu/wp-content/uploads/2018/02/ADirectiveEpub.pdf” type=”big” color=”green” newwindow=”yes”] Full Text Article PDF[/button]

Corresponding Author: Kelsey Grace, gracekel@msu.edu



Advance directives are an important aspect of medical care for the elderly given the uncertainty of health and longevity. In their absence, family and physicians are often left with questions regarding what patient’s wishes would entail if they become incapacitated. Individuals >65 years presenting to the ED were surveyed during the months of June-September 2015 by study investigators regarding their knowledge and utilization of advance directives. 168 patient surveys were completed with a mean age of 77.2 (SD ±7.45 years; range 65-97). Of those, 91% were either ―very familiar‖ or ―somewhat familiar‖ with Advance Directives with 76.1% having some form of documented advance directives in place. Of those who felt family were aware of their wishes, 84.9% had assigned a Medical Durable Power of Attorney. Only a small minority had developed advance directives with their physician’s assistance (6.8%). The majority of patients stated that they had prepared their end of life documents with a Lawyer (72%). Only 35.8% of patients sampled had even mentioned the topic or their specific wishes with their primary care or ED physician. Overall rates of formalized advance directives would appear to be highly utilized in this patient population with little variation based upon respondents’ self-assessment of physical health. A surprising finding was how minor of a role physicians appear to play in the development of ADs. This provides an opportunity to enhance the physician-patient relationship and improve patient education regarding end of care discussions. Physicians should take initiative and begin having these conversations, in order to ensure that patients are making educated decisions and that proper documentation is occurring.

Published on date: February, 2018

DOI: 10.15404/msrj/02.2018.0152

Citation: Grace, K., Carson, M., Grace, A. et al. Advance Directive Status in the Greater Than 65-Year-Old Emergency Department Population, Medical Student Research Journal (2018). doi:10.15404/msrj/02.2018.0152


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9. Tierney WM, Dexter PR, Gramelspacher GP, Perkins AJ, Zhou XH, Wolinsky FD. The effect of discussions about Advance directives on patients’ satisfaction with primary care. J Gen Intern Med. 2001;16(1):32–40. (Patient satisfaction with physicians increases if directives are discussed).

Equator Manuscript Reporting Guidelines

Hello authors,

We at MSRJ are working hard to streamline the manuscript review process to reduce the time between submission date and when a decision is made on final publication.   One of the numerous barriers to fast and efficient manuscript review is something that is under author control – the quality of the submitted manuscript.   In this post, I will describe an indispensable tool all authors should use in preparing a manuscript for publication.

The resource I am referring to is the “Reporting Guideline”.  A reporting guideline is a document that outlines the minimum required content for your manuscript.  It is like a checklist of what information should be included in your manuscript. The purpose of a guideline is to ensure authors provide required information such that a reader knows exactly what you did in your study, and if so desired, they could repeat your study using only your manuscript as a guide. The goal is to ensure all published research papers have proper reporting of details to ensure they can be critically appraised, utilized in systematic reviews, or repeated.

Use of a reporting guideline when writing your manuscript will also help shorten the time it takes from manuscript submission to journal decision.  One of the major delays in the review process occurs when submitted manuscripts have missing information.   This requires the journal to request a resubmission of the manuscript with the missing information, often requiring a second review.  To avoid such a needless delay, we strongly recommend using a reporting guideline when submitting a manuscript to MSRJ.


So what should MSRJ authors do?

(1) Go to The Equator Network website (http://www.equator-network.org/). The Equator Network hosts hundreds of reporting guidelines on many different study design types.  There are reporting guidelines for randomized trials, observational studies, systematic reviews, qualitative research, and case reports, among many others.

(2) On the Equator Network website, find the guideline appropriate to your study type.

(3) Once you have found the appropriate guideline, use the associated checklists to ensure you report all required information.

(4) Finally, cite the guideline you used in your manuscript.

By utilizing the appropriate guideline and adhering to its recommendations, you will ensure a smooth initial review and help improve the quality of research reporting in general.


Mark Trottier, Ph.D.

MSRJ Faculty Advisor