Can the Eyes See What the Mind Doesn’t Know?: The Effects of Preclinical POCUS Training on RUSH Clinical Performances in an Emergency Medicine Clerkship

Objectives:
Point-of-care ultrasound (POCUS) is a modality that providers are increasingly utilizing to answer specific clinical questions at a patient’s bedside in both the inpatient and outpatient settings. Despite the advantages that POCUS provides in clinical settings, its value is wholly dependent on the skill, knowledge, and expertise of the providers who are using it to form a clinical decision. To reach this level of proficiency, providers must have obtained adequate education, instruction, and practice with ultrasound. As the usage of ultrasound continues to grow in medical practice, it is also continuing to grow in medical education, both at the undergraduate and graduate levels. Many medical schools are beginning to incorporate POCUS into their curricula to facilitate better teaching of physical examination and clinical management, as well as anatomy and physiology. While many schools have started incorporating POCUS into their preclinical curricula, the same cannot be said of their clinical curricula. By limiting POCUS education and exposure solely to students’ preclinical years, these medical schools are preventing students from having the opportunity to practice their ultrasound skills on patients and continue the development of their ultrasound skills. By exploring the individual needs and challenges of distributed campus model institutions with a four-year integrated POCUS curriculum, the benefits of POCUS in medical education can be better assessed for medical students. The purpose of this study was to evaluate the effect of integrating preclinical ultrasound into the undergraduate medical education curriculum at an academic medical center utilizing a distributed campus model by assessing fourth-year medical students’ ultrasound performances on the rapid ultrasound for shock and hypotension (RUSH) exam.

Methods:
This study was conducted retrospectively with fourth-year medical students at a school that follows a distributed campus model with two primary campuses. Two cohorts of students were studied over two consecutive years (Cohort 1; Cohort 2). Within Cohort 1, there was a with POCUS-1 group and a without POCUS group. With POCUS-1 has students from Campus A, which is a larger campus that includes a formal POCUS curriculum during the preclinical years. Without POCUS has students from Campus B, which is a smaller campus that offers a limited POCUS curriculum during the preclinical years.
Within Cohort 2, there was a with POCUS-2 group and a minimal POCUS group. With POCUS-2 has students from Campus A, while minimal POCUS has students from Campus B. Following the academic year of those in Cohort 1, the ultrasound education was expanded for Campus B to allow preclinical POCUS training.
The study investigated the utilization of preclinical POCUS on the ability of students to perform RUSH examinations during their Emergency Medicine clerkship rotation. This ability was determined by the scores they received, which were determined by a trained sonographer who was blinded from knowing each student’s preclinical training status, campus, or rotation site.
The differences between mean RUSH exam scores were assessed for statistical significance. The mean RUSH exam scores for each group were compared using a one-tailed, unpaired t-test assuming unequal variance. Statistical significance was considered at a p-value of ≤ 0.05.
The required RUSH examination images included: inferior vena cava (long or trans view), parasternal long view or apical 4-chamber view of the heart, and two additional images that were relevant to the patient’s medical history. These additional images included: Morison’s pouch with hemithorax, splenorenal recess with hemithorax, urinary bladder, aortic sweep, pleural slide, deep vein, optic nerve sheath diameter, or gallbladder.

Results:
The mean RUSH exam score for the 33 matched students from the with POCUS-1 group from Cohort 1 was 83.76%, while this score of the 33 students from the without POCUS group from Cohort 1 was 65.91% (statistically different results with a p-value of 0.003). The mean RUSH exam score for the entire with POCUS-1 group from which the study chose 33 students to match (n=169) was 79.49%, while the mean RUSH exam score for the 33 students who were chosen to match from this group (n=33) was 83.76% (not a statistically significant difference with a p-value of 0.310). However, the mean RUSH exam score for the entire with POCUS-1 group (n=169) was significantly higher than that of the without POCUS group (n=33) (statistically significant difference with a p-value of 0.007).
The mean RUSH exam score of students in the with POCUS-1 group who completed their Emergency Medicine rotation in an academic hospital (n=71) was 84.03%, while the mean RUSH exam score of students in the with POCUS-1 group who completed their Emergency Medicine rotation in a non-academic hospital (n=98) was 76.19% (statistically significant difference with a p-value of 0.020). Additionally, students in the with POCUS-1 group who had their Emergency Medicine rotation in a non-academic hospital scored significantly higher on the RUSH examination than those students in the without POCUS group (statistically significant difference with a p-value of 0.050).
The mean RUSH exam score for students in the with POCUS-2 group from Cohort 2 (n=129) was 84.13%, while the mean RUSH exam score for students in the minimal POCUS group from Cohort 2 (n=14) was 82.14% (not a statistically significant difference with a p-value of 0.401).

Conclusions:
The purpose of this study was to determine the effect of preclinical POCUS training on fourth-year medical students’ abilities to correctly obtain, interpret, and clinically integrate ultrasound images taken during RUSH exams throughout their Emergency Medicine rotation. The results demonstrate that students with a formal preclinical POCUS curriculum that spans the first two years of medical school generally perform better on RUSH examinations than those who do not, regardless of whether the RUSH examinations are done in an academic or non-academic hospital. The results also demonstrate that students exposed to even minimal amounts of preclinical POCUS perform ultrasound at a level that is comparable to those who are exposed to a full preclinical POCUS curriculum.
Notably, the study results also demonstrate a significant difference in the RUSH exam scores between students who completed their rotations at an academic hospital versus a non-academic hospital. Specifically, students who completed their RUSH exams within academic hospitals tended to score higher than students who completed their RUSH exams within non-academic hospitals. This difference suggests that certain factors within academic hospitals, such as higher numbers of POCUS trained physicians and increased accessibility to resources, may ultimately benefit medical students learning to acquire and interpret various ultrasound images during their clinical rotations. Regardless, every variant of the students who had preclinical POCUS training scored significantly higher on the RUSH exam than the entire group of students who had no preclinical POCUS training.
All of these findings illustrate that it is profoundly beneficial for medical students to be exposed to formal POCUS curricula early on in their medical education rather than solely during the clerkship phase, as it enhances their abilities to utilize POCUS to make important diagnoses and formulate essential treatments for patients.

Description:
Point-of-care ultrasound (POCUS) has become an essential modality within medicine and is being increasingly incorporated into undergraduate medical education (UME). However, due to the extensive preclinical curriculum that requires medical students to hone in on their knowledge of basic science, anatomy, and physiology in the first two years, it is difficult to develop a four-year curriculum that incorporates ultrasonography into all years of medical school while still prioritizing learning in the classroom. Our research explored the ability of medical students to adequately obtain and interpret Ultrasound images through RUSH examinations during their Emergency Medicine rotations in their fourth year based on their preclinical ultrasound exposure. We hoped to understand how their scanning abilities may be dependent on the amount of hands-on ultrasonography training they receive during the Preclerkship phase of the curriculum. Being able to develop a curriculum that prioritizes both hands-on and on-paper learning during Preclerkship would help to prepare students in making diagnoses, providing life-saving care, and practicing preventative medicine. Especially within schools that function within a distributed campus model, formulating the perfect curriculum is key for preparing students to become the best physicians possible.