Impact and reception of point-of-care ultrasound training across medical education levels | BMC Medical Education

Previous ultrasound experiences

Most preclinical students (171 out of 183) were in their 4th semester, while the majority of clinical students ( 129 out of 135) were in their 9th or 10th semesters. The German medical education system consists of a 6-year curriculum (12 semesters), with the first two years (semesters 1–4) covering preclinical subjects such as anatomy, physiology, and biochemistry. This is followed by three years (semesters 5–10) focused on clinical subjects, including internal medicine, examination courses, and surgery. The final year, known as the “practical year,” consists of three 4-month clinical rotations: one in internal medicine (mandatory), one in surgery (mandatory), and one in a specialty of the student’s choosing.

First, we aimed to assess the students’ previous experience with ultrasound, as there was no structured hands-on ultrasound training at the Medical School in Marburg. The majority of preclinical students (60.7%) reported having no prior ultrasound experience, whereas 97% of clinical students had used ultrasound to examine at least one patient (Fig. 1a, Supplementary Fig. 2a). However, 57.6% of clinical students had imaged only 1–10 patients, and 3% had no ultrasoundexperience at all. As expected, 95.9% of preclinical students felt unconfident or very unconfident in their sonography skills (Fig. 1a, Supplementary Fig. 2b). Surprisingly, 79.4% of clinical students also reported a lack of confidence, with only 20.6% feeling confident in their abilities. Even among students who had examined 1–10 patients, the majority still felt unconfident in their sonography skills.

Previous Ultrasound Experiences. a, Students’ self-reported confidence in using ultrasound (US), correlated with the number of patients they have previously examined with ultrasound (shown horizontal axis above diagram). b-d, Contexts in which students have had the opportunity to use ultrasound for examinations: (b) overall context for all students, (c) context for preclinical students, and (d) context for clinical students

Overall, 65% of all students had some prior ultrasound experience. To explore the context of these experiences, we asked students about the source of their exposure. Among all students, clinical traineeships accounted for approximately 40% of their ultrasound experiences, while extracurricular university courses contributed 28% (Fig. 1b). For preclinical students, apprenticeships were the most significant source of ultrasound experience (40%), followed by practical courses, which accounted for 34% (Fig. 1c). In contrast, clinical traineeships were the primary source for clinical students (57%), with extracurricular ultrasound courses contributing 32% (Fig. 1d).

Reception and acceptance of portable POCUS systems

To evaluate the suitability of mobile POCUS devices for hands-on sonography courses, we applied the Technology Acceptance Model (TAM), a well-established framework used to analyze user acceptance of information technologies. The first variable we examined was “perceived usefulness” (PU), defined as the extent to which students believe that POCUS would enhance their clinical training (Fig. 2a). Both preclinical and clinical students reported highly significant and affirmative PU scores (Fig. 2b-c). A majority of students (92%) believed that POCUS would improve their clinical skills, and 97% felt that mastering POCUS would contribute to becoming better physicians. Additionally, 91% of participants strongly agreed that acquiring POCUS skills is valuable for medical students.

Survey Results Based on the Three Categories of the Technology Acceptance Model (TAM). a, Likert plots (5-point scale) displaying the survey results, with bars representing the percentage of responses for each Likert score. b-c, Summary of survey results for (b) preclinical students and (c) clinical students, organized by TAM categories. Mean ± standard deviation for each Likert score (5-point scale) is shown. Asterisks denote significance levels from t-tests comparing the means to a neutral point (\(\:{\varvec{\mu\:}}_{\varvec{H0}}=3)\), indicating neither agreement nor disagreement. TAM categories include ATU (Attitude Toward Using), PEU (Perceived Ease of Use), and PU (Perceived Usefulness)

In addition to PU, successful implementation of a POCUS-based hands-on sonography course would likely require that students find POCUS devices easy to use. This is particularly important since more complex systems would require additional instructional time, potentially extending the duration of the sonography course. To assess this potential barrier, we examined “perceived ease of use” (PEU), defined as the degree to which students believed that using POCUS devices for sonography education would be straightforward and uncomplicated (Fig. 2a). The overall PEU score indicated a strong consensus regarding the ease of operating POCUS devices. Clinical students reported a slightly higher PEU score compared to preclinical students (4.59 ± 0.16 vs. 4.41 ± 0.06) (Fig. 2b-c). A significant majority of students (89%) found POCUS devices easy to handle, with only 3% reporting difficulties.

The third variable in the TAM is “attitude towards use” (ATU), which we defined as the degree to which students anticipated positive outcomes from using the devices. The overall ATU score demonstrated a highly significant positive attitude toward incorporating POCUS devices into hands-on sonography courses (Fig. 2). No significant differences were observed in ATU between preclinical and clinical students. Additionally, 95% of students agreed that POCUS should be a permanent part of the medical curriculum, with 78% expressing strong agreement. Despite the current structure of the preclinical curriculum, 91% of students agreed that introducing POCUS early in medical education would be beneficial. Lastly, 97% of students felt that the faculty should increase investment in the availability and instruction of POCUS.

Students’ perspectives on the implementation of POCUS education

Finally, to effectively design a POCUS-based sonography curriculum, it is essential to consider students’ perspectives on the ideal timing for introducing POCUS education and the subjects in which its integration would have the most impact. To gather this information, we asked students two questions: which subjects they believed would benefit most from POCUS education, and when they thought POCUS should be introduced. The suggested subjects are summarized in Fig. 3a, with both preclinical and clinical subjects mentioned at similar frequencies. Overall, the most frequently suggested subjects were anatomy (35.2%) and internal medicine (16.7%).

Students’ Responses Regarding the Implementation of POCUS in Medical Education. a, Sankey plot illustrating the distribution of students’ suggestions regarding the integration of POCUS into various medical education subjects. Responses are divided into preclinical and clinical subjects, with link widths corresponding to the frequency of mentions. Percentages denote the proportion of total responses attributed to each subject or topic. Notably, anatomy (35.2%) and internal medicine (16.7%) were the most frequently mentioned disciplines for potential POCUS application. The data underscore the perceived relevance of POCUS across a wide array of subjects. b, Bar graph represents the distribution of students’ recommendations for the most appropriate stage in medical education to begin POCUS training. The majority of students (57.7%) recommended introducing POCUS education as early as the first semester, while 32.9% suggested starting it during the clinical study phase. An additional 9.1% proposed beginning POCUS training at some point during the preclinical phase. Notably, there was almost no support for delaying it until the Practical Year or excluding it entirely. The data reflect a clear preference for integrating POCUS early in medical education

Interestingly, students also identified physiology and physics as relevant preclinical subjects where ultrasound teaching could be beneficial. Beyond internal medicine, several clinical subjects were frequently recommended for POCUS integration, including gynecology, emergency medicine, surgery, and anesthesiology. Notably, 8.6% of students suggested that POCUS be incorporated into all clinical subjects involving sonographic examinations. Additionally, 7.8% of respondents indicated that practical training sessions, such as physical examination courses, would be suitable for POCUS integration. A small proportion (2.6%) specifically requested a dedicated ultrasound course.

Regarding the timing of POCUS education, a majority of students (57.7%) expressed a preference for introducing POCUS early, beginning in the first semester (Fig. 3b). However, 32.9% favored implementing POCUS during the clinical phase of their studies. Additionally, 9.1% of students recommended starting POCUS education in the preclinical phase, but only after acquiring sufficient foundational knowledge in anatomy.