David Purkarthofer^1,2,3*, Simon Orlob MD^4,5

(1) Medical University of Graz, Neue Stiftingtalstraße 6, Graz, 8010, Styria, Austria

(2) Medizinercorps Graz, Austrian Red Cross, Munzgrabenstraße 151, Graz, 8010, Styria, Austria

(3) Department of Health Studies, FH Joanneum University of Applied Sciences, Alte Poststraße 149, Graz, 8020, Styria, Austria

(4) Institute for Emergency Medicine, University Hospital Schleswig-Holstein, Arnold-Heller-Straße 3, Haus 808, Kiel, 24105, Schlewig-Holstein, Germany

(5) Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5, Graz, 8036, Styria, Austria

*Corresponding Author:  David Purkarthofer (email: mail@davidpurkarthofer.at)

Download article PDF – POCUS Journal 2025;10(2):11-12.

DOI: https://doi.org/10.24908/pocusj.v10i02.19791

Supplementary Material: Figure S1

Dear Editor,

Point of care ultrasound (POCUS) is increasingly integrated into undergraduate and postgraduate medical education. While theoretical knowledge can be efficiently delivered through flipped classrooms or online modules, image acquisition remains a psychomotor skill that requires hands-on practice in small groups with a low learner-to-instructor ratio [1,2].

Instructors may be under pressure to save time or help learners to get the “right” image. In these cases, they often take the probe and manipulate it themselves. While this approach may produce an adequate sonogram in less time, it can inadvertently bypass the learner’s opportunity to develop essential visuospatial understanding, problem-solving strategies, and fine motor coordination. The result is a focus on the product—a clear image—rather than the process of skill acquisition.

In our undergraduate POCUS courses, we frequently observed learners struggling with probe handling, topographic orientation, and image interpretation. These challenges were compounded by inconsistent terminology and limited hands-on learning time. To address this, we developed and implemented a graded escalation strategy designed to maximize learner autonomy, while still providing timely, structured support.

The Four-Step Escalation Strategy

We encourage instructors to follow the sequence in Table 1 when assisting learners in acquiring a specific view.

This model draws inspiration from approaches in simulation-based education, where graduated assistance helps learners retain autonomy while ensuring progressive competence [3]. We train both novice and experienced instructors in this method during simulated teaching sessions and reinforce it by distributing laminated pocket cards that include the steps for teaching POCUS image acquisition (Figure S1).

Reflections and Implications

We found that when instructors resisted the urge to “fix” the image for the learner, the learner often revealed surprising problem-solving abilities. Even if image acquisition took longer, learners retained techniques better and displayed improved orientation skills in subsequent sessions. The model also standardized instructor language and reduced variability in feedback styles.

Respecting learner autonomy in POCUS teaching aligns with broader educational principles: creating a psychologically safe space, fostering deliberate practice, and supporting the development of transferable bedside skills. While our approach was developed for undergraduate courses, it may be equally useful in postgraduate training, interprofessional education, and even continuing professional development.

Conclusion

POCUS training should be viewed as more than a race toward producing a technically perfect image. It represents a critical opportunity to develop learners’ enduring psychomotor abilities, visuospatial reasoning, and diagnostic problem-solving skills. By adopting a structured, graded escalation strategy, instructors can provide timely, targeted assistance while safeguarding learner autonomy. This approach likely supports long-term skill retention, fosters confidence, and enhances competence at the bedside.

Acknowledgments, Artificial Intelligence Use

We thank Suean Pascoe and Aidan Baron for their valuable feedback on earlier drafts of this work. The manuscript was drafted manually; ChatGPT-5 was subsequently used for spell-checking, readability refinement, and translation support for the pocket cards. All generated suggestions were carefully reviewed and adopted at the authors’ discretion.

Ethics Statement

As this is a conceptual work with no involvement of human participants, patient data, or animal subjects, the authors determined that ethical committee approval was not necessary.

Disclosure

None declared.

References

1. Cawthorn TR, Nickel C, O’Reilly M, Kafka H, Tam JW, Jackson LC, Sanfilippo AJ, Johri AM. Development and evaluation of methodologies for teaching focused cardiac ultrasound skills to medical students. J Am Soc Echocardiogr 2014;27(3):302-9. doi: 10.1016/j.echo.2013.12.006

2. Hofer M, Schiebel B, Hartwig HG, Mödder U. Didaktiktraining für Ausbilder in Ultraschallkursen – Evaluation des “Train-the-trainer”-Programms des Medizindidaktischen Pilotprojektes Düsseldorf [Didactic training of ultrasound instructors]. Ultraschall Med 2002;23(4):267-73. German. doi: 10.1055/s-2002-34054

3. Motola I, Devine LA, Chung HS, Sullivan JE, Issenberg SB. Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82. Med Teach 2013;35(10):e1511-30. doi: 10.3109/0142159X.2013.818632