A serious video game for teaching basic point-of-care echocardiography skills: a non-inferiority trial

The use of point-of-care ultrasound (POCUS) is expanding, but providing effective training remains challenging. Serious video games offer a promising, accessible, and cost-effective alternative. This study compares the non-inferiority of the serious game Underwater for learning basic echocardiography skills with that of traditional simulator-based training. This prospective, single-blind, randomized controlled non-inferiority trial was conducted at the Medical University of Vienna. The participants were medical students, all of whom had a basic knowledge of anatomy but no prior experience in cardiac POCUS. Their performance in echocardiography examinations was evaluated using the modified Objective Structured Assessment of Ultrasound Skills (OSAUS) score (4 to 20 points) and its subcategories (1 to 5 points). Following a two-hour workshop and a baseline assessment, the students participated in four training sessions over a two-week period. A final assessment was conducted afterward. A non-inferiority two-sample t-test with a one-sided significance level of 5% was applied to compare the primary outcome – the change in the total modified OSAUS score from baseline to final assessment – between the two groups. From October 3rd to May 5th, 2024, 97 out of 103 participants were analyzed, resulting in a dropout rate of 5.8%. The mean difference in OSAUS scores was − 1.24 ± 3.72 for the simulator and − 0.57 ± 3.51 for the video game group, demonstrating non-inferiority as hypothesized (p < 0.001). No significant differences in image optimization due to hand-eye coordination were observed between the two groups (-0.16 ± 1.40 for simulator vs. -0.23 ± 1.18 for video game, p = 0.780). 63.8% of the video game group and 78.0% of the simulator group found the randomized learning method to be helpful or very helpful. Serious video game-based training was statistically non-inferior to mannequin-based simulation for basic cardiac POCUS hand-eye coordination skills. However, neither modality produced measurable improvement beyond the initial workshop, and both groups showed a small decline in performance over time. These findings indicate equivalence between modalities rather than effectiveness in this reinforcement setting and underscore the importance of longitudinal integration, distributed practice, and deliberate reinforcement when implementing innovative training approaches. The trial was registered on clinicaltrials.gov (NCT06106178; 04/03/2023).