Use of point-of-care ultrasound (POCUS) in French urgent primary care: a national survey of general practitioners in the SOS Médecins network

Use of point-of-care ultrasound (POCUS) in French urgent primary care: a national survey of general practitioners in the SOS Médecins network | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Use of point-of-care ultrasound (POCUS) in French urgent primary care: a national survey of general practitioners in the SOS Médecins network Nawele Boublay, Pascal Rippert, Touria Hajri, Julien Berthiller, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7943149/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Point-of-care ultrasound (POCUS) is increasingly recognized as a valuable diagnostic tool in general practice. However, its actual use among French general practitioners (GPs) working in urgent care settings, such as SOS Médecins, a nationwide network of GPs providing home-based urgent primary care 24/7, remains poorly documented. Objectives: To assess the prevalence, modalities of use, perceived impact, and barriers to the adoption of POCUS among GPs working in the SOS Médecins network across France. Methods: A national cross-sectional online survey was distributed to all eligible SOS Médecins physicians. The questionnaire addressed POCUS usage, clinical indications, equipment access, perceived benefits, training needs, and adoption barriers. Descriptive statistics were used, and comparisons between users and non-users were performed using chi-square or Fisher’s exact tests. Results: Among 211 respondents, 47.4% reported current POCUS use. Statistically significant differences between users and non-users were observed for age group (p = 0.0208) and years of experience in SOS Médecins (p = 0.0034). The most frequent indications included abdominal pain (79.2%), vascular assessment (76.2%), and respiratory symptoms (65.3%). Most users relied on portable devices (69.8%) and performed focused, indication‑driven scans (87.4%). POCUS was perceived as having a positive or very positive impact on triage (86.0%), treatment decisions (81.7%), diagnostic accuracy (67.0%), professional autonomy (59.0%), and the doctor–patient relationship (50.0%). Nevertheless, only 15.6% of users reported billing for POCUS acts. Among non-users, the main barriers were lack of specific training (63.6%), limited time (44.5%), equipment cost (40%), and doubts about clinical utility (23.6%). More than half (54.5%) expressed interest in receiving training. Conclusion: POCUS is currently used by nearly half of SOS Médecins physicians providing urgent primary care in France. Despite strong clinical interest and perceived utility, adoption remains limited by training gaps, structural barriers, and lack of clear financial incentives. Point-of-care ultrasound POCUS prevalence general practice primary care urgent care France SOS Médecins Figures Figure 1 Figure 2 Figure 3 Introduction Point-of-care ultrasound (POCUS) is increasingly recognized as a valuable diagnostic modality across both emergency and primary care settings. POCUS, defined as a clinician-performed bedside imaging tool to address focused clinical questions, enhances physical examination, expedites diagnostic decisions, and reduces dependency on traditional imaging modalities [ 1 – 3 ]. When systematically integrated into general practice workflows, POCUS has also been associated with greater diagnostic precision, improved triage decisions, and safer, more efficient patient management [ 4 , 5 ]. In primary care, studies from European countries such as Norway or Switzerland have documented the growing integration of POCUS into routine general practice supported by dedicated strategies, evolving reimbursement models, and improved access to portable devices [ 6 – 9 ]. In Norway, a national reimbursement‑based register study reported that approximately 30% general practitioners (GPs) had claimed at least one POCUS procedure in 2016 [ 7 ]. In Switzerland, a cross-sectional survey among primary care physicians found that the most commonly self-performed ultrasound scans were abdominal (57.9%) and musculoskeletal (22.0%) examinations [ 6 ]. Together, these national experiences reflect a broader trend: the progressive shift of ultrasound from hospital-based radiology units to outpatient and community care, where GPs are developing new practice models and overcoming structural barriers [ 10 ]. In France, however, the diffusion of POCUS into general practice remains limited. While several medical theses have explored GPs’ perceptions and training needs regarding POCUS, no peer-reviewed national data are currently available on its actual use in urgent primary care of its role in ensuring continuity of care. However, significant barriers persist in the French medical context. These include the absence of ultrasound training during undergraduate and postgraduate medical education, lack of formal recognition or information about remuneration for POCUS acts, equipment costs, and time constraints during consultations [ 11 , 12 ]. As a result, the implementation of POCUS within French general practice remains slow and inconsistent. SOS Médecins is a nationwide network of approximatively 1,300 GPs providing 24/7 urgent and unplanned primary care, primarily through home visits, across more than 60 locations in France. This unique organization plays a key role in the out-of-hospital management of acute conditions, particularly among older or frail populations [ 13 ]. As such, SOS Médecins offers a critical setting to evaluate POCUS integration. These physicians often work in unscheduled, home-based contexts where patients present with acute symptoms, such as abdominal pain, dyspnea, or trauma, and lack immediate access to radiological assessment. In such situations, POCUS could provide timely diagnostic information to guide early clinical decisions [ 11 , 12 ]. While some local projects have emerged, mainly in the form of unpublished medical theses or informal pilot programs, no unified national strategy presently exists to promote structured POCUS training and sustainable integration into French general practice. This challenge is not exclusive to France, as similar situation has been reported in other European settings, including Scandinavia, where training programs have demonstrated clinical value but have not yet resulted in widespread daily use among GPs [ 14 ]. This study aims to assess the prevalence, modalities of use, and perceived impact of POCUS among GPs providing urgent medical serviceat a national level. It also explores how the tool is used (devices, indications, frequency), practitioners’ perceptions, and barriers to broader adoption in this unique care setting. Methods Study Design and Objectives We conducted a nationwide, cross-sectional, descriptive study between March 2025 and September 2025. The primary objective was to describe the prevalence of point-of-care ultrasound (POCUS) use among GPs working within the SOS Médecins network in France. Secondary objectives included identifying the modalities of POCUS use, perceived barriers and facilitators, and the characteristics of practitioners using POCUS in routine practice. Ethics The study protocol was reviewed and approved by the Lyon University Hospital Ethics Committee (Comité d’Éthique des Hospices Civils de Lyon – IRB number 00014232). All participants were informed about the study objectives, data handling procedures, and their rights, including the option to withdraw at any time. Data were collected anonymously and handled in accordance with General Data Protection Regulation (GDPR). Setting and Population SOS Médecins is a nationwide network of approximately 1,300 GPs providing 24/7 urgent and continuity of primary care in France, primarily through home visits. The study targeted all GPs actively practicing within the SOS Médecins France network at the time of the survey. Sample Size The eligible population consisted of approximately 1,300 physicians. No a priori sample size calculation was performed, as no prior national data were available to inform a specific hypothesis of interest or expected response rate. Incomplete or clearly inconsistent responses were excluded from analysis. Data Collection An anonymous, structured, self-administered questionnaire was developed based on existing literature and expert input. The survey comprised 37 items covering the following domains: Demographics and professional characteristics Current access to and use of POCUS Clinical indications and anatomical targets Perceived impact on clinical decision-making Training history and learning needs Barriers and facilitators to POCUS adoption Selection of clinical indications and anatomical targets was guided by international studies, ensuring comparability with prior research and enhancing generalizability [ 8 , 9 , 15 , 16 ]. The perceived impact of POCUS on patient management (including time-saving, diagnostic assistance, and therapeutic decision-making) was assessed using a 5-point Likert scale, as recommended in previous studies [ 17 , 18 ]. The questionnaire was built and distributed via a secure online platform (RedCap©) [ 19 ]. Physicians were first contacted by email via the national SOS Médecins mailing list. Two reminder emails were sent at three-week intervals. Additionally, the study was presented at the SOS Médecins national congress in June 2025, where a QR code was displayed to facilitate voluntary participation. Participation was voluntary and without financial compensation. Statistical Analysis Data were analyzed using SAS software, version 9.4 (SAS Institute Inc., Cary, NC, USA). Descriptive statistics were used to summarize participant characteristics and response distributions. Categorical variables were described by frequencies and percentages. Chi-square or Fisher’s exact tests were used for comparisons where relevant, with a significance threshold of p < 0.05. Results 1. Population Characteristics GPs characteristics are provided in Table 1 . Out of approximately 1,300 physicians contacted, 211 completed the questionnaire (16%): 110 non-users of point-of-care ultrasound (POCUS) and 101 current users. The majority were male in both groups (80.9% among non-users, 82.2% among users). Age distribution differed significantly between users and non-users (p = 0.0208). POCUS users were mainly in mid‑career (35–44 years; 43.6% vs. 30.9%), whereas non‑users were more often at the beginning (< 35 years; 20% vs. 14.9%) or end (≥ 65 years; 10.9% vs. 0.99%) of their career. Table 1 Participant characteristics by use of point-of-care ultrasound (POCUS) among SOS Médecins physicians. Variable Modality POCUS users (n = 101) N (%) Non-users (n = 110) N (%) p-value Age group (years) 25–34 15 (14.9%) 22 (20.0%) 35–44 44 (43.6%) 34 (30.9%) 45–54 21 (20.8%) 21 (19.1%) 55–64 20 (19.8%) 21 (19.1%) ≥ 65 1 (0.99%) 12 (10.9%) 0.0208 Gender Male 83 (83%) 89 (80.9%) Female 17 (17%) 21 (19.1%) 0.6943* Years in SOS practice (years) 20 19 (18.8%) 33 (30.0%) 0.0034 Practice environment Urban 90 (89.1%) 100 (90.9%) 0.6626 Peri-urban 49 (48.5%) 39 (35.5%) 0,0546 Rural 14 (13.9%) 14 (12.7%) 0,8083 Access to radiologist Easy 31 (30.7%) 43 (39.1%) Moderate 60 (59.4%) 55 (50.0%) Difficult 10 (9.90%) 12 (10.9%) 0.3744 Values are presented as number (percentage). Comparisons between users and non-users were made using Chi-square or Fisher’s exact test where appropriate. * One participant selected ‘Other / No answer’ for gender; this response was excluded from group comparison due to insufficient sample size. Statistically significant differences (p < 0.05). A significant difference was also observed regarding years of experience in SOS Médecins (p = 0.0034). Mid-career physicians (5–20 years) were more likely to use POCUS (63.4%), while early-career and senior doctors were more represented among non-users (31.8% and 30.0%, respectively). Practice settings were not different across groups, with most respondents working in urban or peri-urban areas (urban: approximatively 90% for both users and non-users; peri-urban: 35.5% non-users vs. 48.5% users). Access to radiologists was not significantly different (p = 0.3744), with most describing it as moderate or difficult (non-users: 69.9%; users: 69.3%). 2. Use and Non-Use of POCUS 2.1. Current Users (n = 101) Most users had been practicing POCUS for more than 5 years (37.5%), followed by 1–3 years (32.3%) and 3–5 years (21.9%). Daily use was reported by 41.1%, while 33.7% used it weekly. The majority (87.4%) reported performing focused scans for specific clinical indications, rather than general imaging. 2.2. Non-Users (n = 110) Non-users accounted 52.1% of respondents. When asked whether specific training might encourage adoption, 54.5% responded affirmatively, 27.3% were unsure, and 18.2% indicated no interest. Further details on reported barriers to adoption, including perceived usefulness, time constraints, and access or equipment issues, are presented in section 6 (Barriers to Use and Training Gaps). 3. Indications and Anatomical Targets Among users, the most common indications for using POCUS were Abdominal pain (79.2%), Vascular assessments (76.2%), Respiratory symptoms (65.3%), Chest pain (33,7%), Trauma assessment (29,7%) and Musculoskeletal evaluation (22,8%) (Fig. 1 ). Additional uses reported in open comments included bladder volume evaluation, gynecological indications (e.g. suspected ectopic pregnancy, ovarian cyst), as well as ocular, thyroid, and testicular assessments. 4. Access to Equipment 69,8% of POCUS users relied on portable ultrasound devices, while 12.5% used fixed devices and 17.7% reported using both. Access to equipment was not perceived as a major barrier: only 2.7% of non-users cited it explicitly. This contrast highlights a distinction between objective accessibility and subjective perception of cost as a barrier. 5. Perceived Impact of POCUS The perceived clinical value of POCUS was high among users across all assessed dimensions. As shown in Fig. 2 , the majority of respondents rated its impact as positive or very positive on intellectual satisfaction (91.4%), patient triage (86.0%), diagnostic efficiency (67.0%), and treatment decisions (81.7%). The perceived impact on reducing additional testing was slightly lower (49.5%). Additionally, qualitative comments reinforced this favorable perception. For example, one participant described POCUS as “the stethoscope of the 21st century,” while another stated: “It has revolutionized my practice and decision-making processes.” Notably, even among non-users, 57.3% rated the potential impact of POCUS as positive or very positive, indicating a strong underlying interest. 6. Barriers to Use and Training Gaps Among non-users, the main barriers included Lack of training (63.6%), Lack of time (44.5%), Equipment cost (40%) and Perceived low utility (23,6%) (Fig. 3 ). Free-text responses also highlighted recurring concerns about medico-legal uncertainties, technical proficiency, and the absence of billing incentives, all of which further discouraged adoption. Among users, 89.5% reported having some form of training, including a University or Inter-university Diploma in POCUS (22,8%), industry-sponsored sessions (15,8%), continuing medical education (61.4%), and self-directed learning (29,7%). Yet only 15,6% reported integrating POCUS into their billing practices. 7. Suggestions and Open Comments Approximately one-quarter of respondents (25.1%, n = 53) provided qualitative comments, offering rich insights into both clinical practice and system-level challenges. Six major themes emerged: Clinical utility and evolving standards : Several respondents described POCUS as “indispensable” or “revolutionary” in acute care contexts. Comments emphasized its role in ruling out life-threatening conditions, enhancing diagnostic speed, and improving outpatient triage: “It is the stethoscope of the 21st century.” “I can’t work without it anymore.” Training needs and mentorship : Many called for structured, hands-on training pathways tailored to the SOS Médecins context. Proposals included internal mentorship programs, partnerships with existing certified trainers, and echo-first initiatives modelled on local examples: “The best training I had was from fellow SOS physicians.” “Why not have internal training by experienced DU-certified colleagues?” Institutional and financial recognition : A dominant theme was the demand for a dedicated billing code, analogous to those available for electrocardiography (ECG), and better guidance regarding the French medical classification system for procedures and billing (Classification Commune des Actes Médicaux- CCAM): "A specific billing code would recognize the time, cost and skill invested." "We need clearer guidelines on how to code ultrasound procedures." Equipment costs and technical barriers : Respondents frequently cited the high cost of quality devices and the difficulty of fitting scans into short home visits. “If only performant machines weren’t so expensive.” “Adds 15 + minutes per consultation, hard to manage in urgent care.” Professional identity and patient rapport : Several comments highlighted how POCUS reinforces clinical credibility, fosters patient trust, and preserves GPs’ central role in a shifting care landscape: “It boosts patient trust and strengthens the doctor-patient bond.” “We must stay central in the system. POCUS helps us remain indispensable.” Strategic vision for the future : Beyond individual practice, a number of respondents emphasized the need for a national strategy, equipment supports from the network, and a shared vision for integrating POCUS sustainably in out-of-hospital care. “POCUS is a necessity, not an option.” “SOS should actively promote training and access for all.” Discussions 1. Principal findings This national survey provides the first quantification of point-of-care ultrasound (POCUS) use among GPs working within SOS Médecins, a nationwide network delivering urgent and continuity of primary care in France. Nearly half of the respondents (47.4%) reported using POCUS in their current practice. POCUS adoption was lowest among the youngest and oldest physicians, and highest in intermediate age groups—particularly among those aged 36 to 55. Among users, the tool was primarily employed for the evaluation of acute abdominal pain, vascular assessments and respiratory symptoms. Most used portable devices and performed targeted exams based on specific clinical suspicions. Non-users, who represent 52.6% of the sample, primarily cited lack of specific training, time constraints during consultations, and the cost of equipment cost as key barriers. Notably, more than half of the non-users expressed interest in POCUS training. These findings highlight both the advanced stage of informal diffusion of POCUS into frontline urgent general practice and the structural constraints that still limit its broader and safer integration. In both user and non-user groups, the lack of financial recognition was a recurring concern. Many users reported not billing the act due to the absence of a dedicated code, while some non-users highlighted the inability to valorize the act financially as a disincentive. This underscores a systemic gap between clinical practice and the current regulatory and billing framework in France. 2. Comparison with existing literature The 47.4% adoption rate observed in our study ranks among the highest reported in primary care settings internationally. In Denmark, a recent national survey found that 11.5% of GPs reported active POCUS use [ 20 ]. While the methodological contexts differ, particularly regarding response rates, this comparison highlights the notable diffusion of POCUS within the SOS Médecins network. In Hong Kong, a cross-sectional evaluation of primary care physicians reported a prevalence of 22.5% [ 21 ]. In Switzerland, a nationwide study combining billing data and survey responses found that 49% of general practitioners had billed at least one ultrasound examination between 2004 and 2018. While this figure does not reflect regular or systematic use, the authors reported a steady increase in the number of users and procedures over time, suggesting a progressive diffusion of ultrasound into primary care settings [ 15 ]. More recently, Zumstein et al. (2024) found that 56.5% of Swiss GPs owned an ultrasound device, and 77% of reported scans were self-performed, particularly in rural or urgent care settings, underscoring the relevance of POCUS in areas with limited access to diagnostic imaging [ 22 ]. Although few international studies provide precise or methodologically comparable prevalence, several investigations support the growing integration of POCUS in primary care. Kornelsen et al. reported frequent use and positive experience with POCUS among rural family physicians in British Columbia, Canada, underlining its relevance in remote or resource‑limited settings [ 23 ]. By contrast, our findings suggest more limited uptake in rural zones within the French context. Despite an overall adoption rate of 47.4%, only 13,9% of users in our study practiced in rural areas, indicating that access to POCUS may still be unequal depending on geographic context. This result should be interpreted in light of the fact that SOS Médecins operates predominantly in urban and peri-urban areas, which partly explains the low percentage of rural practitioners in our sample. This disparity nonetheless underscores the need for targeted implementation strategies in underserved or resource-limited regions. In Norway, Myklestul et al. analysed national health‑insurance reimbursement data and found that the number of GPs performing POCUS increased from 479 in 2009 to 2 078 in 2016; the number of registered scans rose from 8 962 to 55 921 over the same period. By 2016, about 30% of Norwegian GPs had billed for POCUS, although three out of four scanning GPs performed fewer than 10 scans per year [ 7 ]. Our finding of a U-shaped distribution in POCUS use—with the lowest adoption among the youngest and oldest physicians, and the highest among those aged 36 to 55—may reflect generational differences in exposure and training. This trend aligns only partially with international observations. In the United States, a national survey among family medicine residents, faculty, and graduates found that while 95.6% of respondents considered POCUS important in family medicine, only 5.4% reported feeling extremely comfortable using it. Notably, residents (younger physicians) were more comfortable and had significantly more prior POCUS training than faculty and graduates, who are likely to include older physicians. This supports the hypothesis that many senior doctors were trained before ultrasound became part of family medicine curricula, leading to a persistent training gap [ 24 ]. Conversely, among younger physicians, interest in POCUS appears to grow as clinical experience accumulates. A recent Hungarian study showed that newly graduated GPs were motivated to integrate ultrasound into practice as a way to enhance diagnostic autonomy and clinical confidence. However, 59.5% acknowledged limited familiarity with its indications and use, suggesting that low early-career adoption may be more a matter of opportunity than reluctance [ 25 ]. Together, these findings support our interpretation of a generational gradient in exposure and training, rather than intrinsic resistance based on age. Barriers identified in our study, training gaps, lack of time, and cost, mirror those noted in multiple international investigations. In a U.S. primary care–oriented survey, Nathanson et al. (2023) found that lack of trained providers, equipment cost, and limited funding for training were the most common obstacles [ 26 ]. In Australia, Arnold et al. (2023) reported similar challenges, including high device cost and difficulties in recouping expenses through reimbursement [ 27 ]. Yamada et al. (2024) further documented that nearly half of physicians cited limited training opportunities and access to ultrasound machines as key barriers [ 28 ]. Even in hospital-based settings, Resop et al. (2025) observed consistent constraints across specialties, particularly regarding training and infrastructure support [ 29 ]. In terms of training, our findings are consistent with those of Ben Shitrit et al. (2025), who demonstrated in a pre-post design that a focused abdominal POCUS training program significantly improved primary care physicians’ skills, confidence, and frequency of use [ 30 ]. Similarly, Andersen et al. (2022) explored how Danish GPs strive to acquire ultrasound skills, emphasizing the role of self-directed learning and peer-to-peer mentorship in the absence of formalized training frameworks [ 31 ]. In France, emergency physicians have developed structured POCUS training pathways and defined minimum skill standards, as outlined in their national competency framework [ 32 ]. This formalization has contributed to broader and safer integration within their specialty. By contrast, general practice training still lacks mandatory ultrasound teaching, leaving most young GPs untrained upon graduation. Continuing education, though essential, cannot replace a structured initial curriculum tailored to primary care needs. Moreover, our observation that many respondents use POCUS without formal recognition or reimbursement resonates with the notion of informal or “hidden integration” of POCUS seen in European general practice settings, as discussed in the systematic review by Sorensen et al. [ 33 ]. 3. Strengths and limitations This is the first national-level study to investigate both the prevalence and practical modalities of POCUS use among GPs working in French urgent primary care. Its main strengths include the inclusion of both users and non-users, the analysis of perceived barriers, impact, and training needs, as well as the study’s national scope. The population was clearly defined, focusing exclusively on GPs working within the SOS Médecins network, which ensures homogeneity in practice context and enhances the interpretability of findings within urgent primary care. Limitations include the response rate (16%), which may raise concerns regarding potential selection bias, particularly the risk of overrepresentation of physicians already interested in ultrasound. However, this bias appears limited. The nearly equal distribution between users (47,4%) and non-users (52,6%) suggests no major differential response. Additionally, key demographic variables (age, gender, experience) were broadly distributed. Promotion through multiple channels, including a national congress, further supports the diversity of the sample. While the response rate remains modest, the internal balance supports the credibility of the findings. Still, we acknowledge that this participation rate limits the generalizability of our findings to all SOS Médecins physicians or to GPs in family medicine. Because some survey questions allowed multiple answers, certain reported frequencies may overlap, and total percentages may exceed 100%. The study also highlights a regulatory grey area, as several respondents reported using POCUS routinely without access to formal training pathways, institutional validation mechanisms, or dedicated billing frameworks. In France, there is currently no requirement for GPs to hold a specific certification to conduct ultrasound examinations, as long as they consider themselves competent and can justify it in case of litigation, in line with current medico-legal standards. This situation is comparable to other procedures commonly used in primary care, such as ECG, which are often self-taught and performed without formal accreditation. 4. Implications and future directions POCUS appears increasingly embedded in the diagnostic routines of urgent primary care GPs in France. The strong adoption rate of POCUS, combined with the high level of interest in further training among both users and non-users, underscores its perceived value and relevance. To support safe and sustainable integration of POCUS in primary care, future initiatives should focus on the following complementary levels of action: Developing structured undergraduate training and defining core competencies for general practitioners. Integrating ultrasound education into early medical training is essential to prepare future GPs for the evolving scope of clinical practice. National curricula should clearly define the competencies relevant to general practice and be informed by robust evidence on the utility and safety of POCUS in unselected primary care populations [ 33 ].; Expanding continuing medical education opportunities for practicing GPs . Short-format, high-yield training programs focused on common and high-impact indications (e.g. abdominal pain, dyspnea, trauma) have shown strong potential to improve diagnostic confidence and clinical decision-making in primary care contexts [ 34 ]. These should be made more widely accessible and standardized. Fostering local initiatives within the SOS Médecins network. Internal training, structured mentorship, and collaborative image review activities—whether formal or peer-led—can support the development and maintenance of skills. Such initiatives could be implemented both locally (within each association) and nationally to build a shared culture of quality and safety. Enhancing financial and administrative recognition. Administrative barriers remain significant. Improving awareness of existing billing codes and advocating for clearer, dedicated reimbursement mechanisms are essential to ensure equitable access and long-term integration [ 35 ]. Further studies are needed to assess the clinical and cost-effectiveness of POCUS in French primary care, including its effects on referral rates, diagnostic delay, and patient outcomes. Implementation research should also explore the feasibility of regional mentorship networks or hospital-GP collaborations to foster real-time learning and quality control, as suggested by prior studies linking POCUS to reduced diagnostic uncertainty and healthcare utilization [ 36 ]. Although this study focused on GPs working in urgent and unscheduled care, its findings raise broader questions about the potential use of POCUS in family medicine. Several facilitating factors identified here, such as perceived diagnostic value, clinical autonomy, and professional satisfaction, are likely shared by GPs in family medicine. In the context of growing medical deserts, where access to specialist consultations or imaging facilities is often limited, POCUS could play a valuable role in enhancing diagnostic equity and reducing avoidable delays. Conclusion This national survey provides the first detailed insight into the use of POCUS among general practitioners working in urgent primary care within the SOS Médecins network. With an adoption rate of 47.4% among respondents, our findings highlight a substantial but heterogeneous uptake, particularly influenced by physician age, training background, and access to equipment. While the overall response rate (16%) limits generalizability, the balanced representation of both users and non-users suggests that these results offer a credible reflection of current trends and perceptions within this unique out-of-hospital care model. The strong training demand among non-users and the positive perceptions reported by users indicate a clear momentum toward broader and safer integration of POCUS in French primary care. Policymakers and professional bodies should now focus on developing and structuring undergraduate POCUS education within medical schools, expanding accessible continuing training programs, improving awareness and usability of existing billing pathways, establishing appropriate reimbursement frameworks, and fostering local mentorship initiatives to ensure safe and sustainable implementation. Further research should evaluate the clinical and economic impact of POCUS in primary care. Abbreviations GDPR: General Data Protection Regulation GP: General practitioners POCUS: Point-of-care ultrasound Declarations Ethics approval and consent to participate The Lyon University Hospital Ethics Committee confirmed that this study did not fall within the scope of French Jardé law[37] and therefore did not require the consent of participants. However, all procedures performed in this study were in accordance with the 1964 Helsinki Declaration Consent for publication Not applicable. Availability of data and materials Deidentified data may be available in French from the corresponding author on reasonable request. Competing interests PB is a member of the scientific committee of SOS Médecins. The other authors declare no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors’ contributions All authors have contributed substantially to this work and meet criteria for authorship as stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals, and each authors’ contribution is listed below: Study concept and design: NB, PB, JB, AMS Acquisition of data: PR, NB Analysis and interpretation of data: TH, NB Drafting of the manuscript: NB, PB Critical revision of the manuscript for important intellectual content: all authors All authors have read and approved this final version of the manuscript. Acknowledgements The authors thank all the GPs who responded to the questionnaire. References Ali N, Soomar SM, Waheed S. Point-of-care ultrasound training in low-income countries: a need of time. Annals Med Surg. 2023;85:1356. https://doi.org/10.1097/MS9.0000000000000397 . Fraleigh CDM, Duff E. Point-of-care ultrasound: An emerging clinical tool to enhance physical assessment. 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Fam Pract. 2021;38:80–7. https://doi.org/10.1093/fampra/cmaa080 . Touhami D, Merlo C, Hohmann J, Essig S. The use of ultrasound in primary care: longitudinal billing and cross-sectional survey study in Switzerland. BMC Fam Pract. 2020;21:127. https://doi.org/10.1186/s12875-020-01209-7 . Di Nisio M, van Es N, Büller HR. Deep vein thrombosis and pulmonary embolism. Lancet. 2016;388:3060–73. https://doi.org/10.1016/S0140-6736(16)30514-1 . Joshi A, Kale S, Chandel S, Pal DK. Likert Scale: Explored and Explained. Curr J Appl Sci Technol. 2015;396–403. https://doi.org/10.9734/BJAST/2015/14975 . Likert R. A technique for the measurement of attitudes. Archives Psychol. 1932;22 140:55–55. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inf. 2009;42:377–81. https://doi.org/10.1016/j.jbi.2008.08.010 . Andersen CA, Brodersen JB, Graumann O, Davidsen AS, Jensen MB. Factors affecting point-of-care ultrasound implementation in general practice: a survey in Danish primary care clinics. BMJ Open. 2023;13:e077702. https://doi.org/10.1136/bmjopen-2023-077702 . Ng APP, Liu KSN, Wong ZCT, Tang ZHW, Wan EYF, Yu EYT, et al. Knowledge, attitude, practices, and perceived barriers to using point-of-care ultrasound by Asian primary care physicians – a mixed method study. BMC Health Serv Res. 2024;24:1344. https://doi.org/10.1186/s12913-024-11865-5 . Zumstein N, Merlo C, Essig S, Auer R, Tal K, Hari R. The use of diagnostic ultrasound by primary care physicians in Switzerland - a cross-sectional study. BMC Prim Care. 2024;25:246. https://doi.org/10.1186/s12875-024-02491-5 . Kornelsen J, Ho H, Robinson V, Frenkel O. Rural family physician use of point-of-care ultrasonography: experiences of primary care providers in British Columbia, Canada. BMC Prim Care. 2023;24:183. https://doi.org/10.1186/s12875-023-02128-z . Ludden-Schlatter A, Kruse R, Mahan R, Stephens L. Point-of-Care Ultrasound Attitudes, Barriers, and Current Use Among Family Medicine Residents and Practicing Physicians. PRiMER. 2023;7. https://doi.org/10.22454/PRiMER.2023.967474 . Kiss-Kovács R, Morvai-Illés B, Varga A, Ágoston G. Is it worth trying? A cross-sectional study on the implementation of point-of-care ultrasound in Hungarian primary care. BMC Prim Care. 2024;25:328. https://doi.org/10.1186/s12875-024-02578-z . Nathanson R, Williams JP, Gupta N, Rezigh A, Mader MJ, Haro EK, et al. Current Use and Barriers to Point-of-Care Ultrasound in Primary Care: A National Survey of VA Medical Centers. Am J Med. 2023;136:592–e5952. https://doi.org/10.1016/j.amjmed.2023.01.038 . Arnold AC, Fleet R, Lim D. Barriers and Facilitators to Point-of-Care Ultrasound Use in Rural Australia. Int J Environ Res Public Health. 2023;20:5821. https://doi.org/10.3390/ijerph20105821 . Yamada T, Soni NJ, Minami T, Kitano Y, Yoshino S, Mabuchi S, et al. Facilitators, barriers, and changes in POCUS use: longitudinal follow-up after participation in a national point-of-care ultrasound training course in Japan. Ultrasound J. 2024;16:34. https://doi.org/10.1186/s13089-024-00384-3 . Resop DM, Bales B, Theophanous RG, Koehler J, Boyd JS, Mader MJ, et al. Multispecialty comparison of point-of-care-ultrasound use, training, and barriers: a national survey of VA medical centers. Ultrasound J. 2025;17:25. https://doi.org/10.1186/s13089-024-00398-x . Ben Shitrit I, Ilan K, Shmueli M, Karni O, Hasidim AA, Cicurel A, et al. Continuing professional development for primary care physicians: a pre-post analysis of a focused abdominal point-of-care ultrasound pilot training. BMC Med Educ. 2025;25:678. https://doi.org/10.1186/s12909-025-07152-4 . Andersen CA, Espersen M, Brodersen J, Thomsen JL, Jensen MB, Davidsen AS. Learning strategies of general practitioners striving to achieve point-of-care ultrasound competence: a qualitative study. Scand J Prim Health Care. 2022;40:67–77. https://doi.org/10.1080/02813432.2022.2036483 . Premier niveau de compétence pour. l’échographie clinique en médecine d’urgence. Recommandations de la Société française de médecine d’urgence par consensus formalisé | Request PDF. ResearchGate. https://doi.org/10.1007/s13341-016-0649-5 Sorensen B, Hunskaar S. Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations. Ultrasound J. 2019;11:31. https://doi.org/10.1186/s13089-019-0145-4 . Andersen CA, Holden S, Vela J, Rathleff MS, Jensen MB. Point-of-Care Ultrasound in General Practice: A Systematic Review. Ann Fam Med. 2019;17:61–9. https://doi.org/10.1370/afm.2330 . Løkkegaard T, Todsen T, Nayahangan LJ, Andersen CA, Jensen MB, Konge L. Point-of-care ultrasound for general practitioners: a systematic needs assessment. Scand J Prim Health Care. 2020;38:3–11. https://doi.org/10.1080/02813432.2020.1711572 . Phillips H, Sukheja N, Williams S, La Forgia A, Nixon G, McArthur LA, et al. Point-of-care ultrasound in general practice: an exploratory study in rural South Australia. Rural Remote Health. 2023;23:7627. https://doi.org/10.22605/RRH7627 . Toulouse E, Masseguin C, Lafont B, McGurk G, Harbonn A, Roberts A. French legal approach to clinical research. Anaesth Crit Care Pain Med. 2018;37:607–14. https://doi.org/10.1016/j.accpm.2018.10.013 . Additional Declarations Competing interest reported. PB is a member of the scientific committee of SOS Médecins. The other authors declare no competing interests. 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16:23:08","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":125997,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7943149/v1/eb5374331a71be888b27f1cf.html"},{"id":95567436,"identity":"3094e9d2-6aea-47a7-a1ce-074960823223","added_by":"auto","created_at":"2025-11-10 16:23:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30190,"visible":true,"origin":"","legend":"\u003cp\u003eClinical indications for point-of-care ultrasound among current users (n = 101).\u003c/p\u003e\n\u003cp\u003eMultiple responses allowed. Values represent number of respondents.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7943149/v1/de5b6c38e2d47196bcb56b59.png"},{"id":95567438,"identity":"7d104d1c-757e-4035-8a5a-ecf5aa68aa5b","added_by":"auto","created_at":"2025-11-10 16:23:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":73152,"visible":true,"origin":"","legend":"\u003cp\u003ePerceived impact of POCUS were made among current users (n = 101) on a 5-point Likert scale (1 = very negative; 5 = very positive).\u003c/p\u003e\n\u003cp\u003eMissing responses were excluded.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7943149/v1/9092920d7b10cb633ff63c6c.png"},{"id":95567437,"identity":"368e8ac9-aafa-47c5-89c7-eedca6ea62c5","added_by":"auto","created_at":"2025-11-10 16:23:07","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":23894,"visible":true,"origin":"","legend":"\u003cp\u003eReported barriers to adopting POCUS among non-users (n = 111).\u003c/p\u003e\n\u003cp\u003eMultiple responses allowed. Values represent number of respondents.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7943149/v1/54cd38371488c4ba8f6dffd2.png"},{"id":95660116,"identity":"c94e66c4-2447-4a6c-a313-701db6032ee4","added_by":"auto","created_at":"2025-11-11 16:30:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1203045,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7943149/v1/61ee35c9-3677-40c2-85f6-3562663d13e4.pdf"}],"financialInterests":"Competing interest reported. PB is a member of the scientific committee of SOS Médecins. The other authors declare no competing interests.","formattedTitle":"Use of point-of-care ultrasound (POCUS) in French urgent primary care: a national survey of general practitioners in the SOS Médecins network","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePoint-of-care ultrasound (POCUS) is increasingly recognized as a valuable diagnostic modality across both emergency and primary care settings. POCUS, defined as a clinician-performed bedside imaging tool to address focused clinical questions, enhances physical examination, expedites diagnostic decisions, and reduces dependency on traditional imaging modalities [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. When systematically integrated into general practice workflows, POCUS has also been associated with greater diagnostic precision, improved triage decisions, and safer, more efficient patient management [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn primary care, studies from European countries such as Norway or Switzerland have documented the growing integration of POCUS into routine general practice supported by dedicated strategies, evolving reimbursement models, and improved access to portable devices [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Norway, a national reimbursement‑based register study reported that approximately 30% general practitioners (GPs) had claimed at least one POCUS procedure in 2016 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In Switzerland, a cross-sectional survey among primary care physicians found that the most commonly self-performed ultrasound scans were abdominal (57.9%) and musculoskeletal (22.0%) examinations [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Together, these national experiences reflect a broader trend: the progressive shift of ultrasound from hospital-based radiology units to outpatient and community care, where GPs are developing new practice models and overcoming structural barriers [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn France, however, the diffusion of POCUS into general practice remains limited. While several medical theses have explored GPs\u0026rsquo; perceptions and training needs regarding POCUS, no peer-reviewed national data are currently available on its actual use in urgent primary care of its role in ensuring continuity of care.\u003c/p\u003e\u003cp\u003eHowever, significant barriers persist in the French medical context. These include the absence of ultrasound training during undergraduate and postgraduate medical education, lack of formal recognition or information about remuneration for POCUS acts, equipment costs, and time constraints during consultations [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. As a result, the implementation of POCUS within French general practice remains slow and inconsistent.\u003c/p\u003e\u003cp\u003eSOS M\u0026eacute;decins is a nationwide network of approximatively 1,300 GPs providing 24/7 urgent and unplanned primary care, primarily through home visits, across more than 60 locations in France. This unique organization plays a key role in the out-of-hospital management of acute conditions, particularly among older or frail populations [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. As such, SOS M\u0026eacute;decins offers a critical setting to evaluate POCUS integration. These physicians often work in unscheduled, home-based contexts where patients present with acute symptoms, such as abdominal pain, dyspnea, or trauma, and lack immediate access to radiological assessment. In such situations, POCUS could provide timely diagnostic information to guide early clinical decisions [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile some local projects have emerged, mainly in the form of unpublished medical theses or informal pilot programs, no unified national strategy presently exists to promote structured POCUS training and sustainable integration into French general practice. This challenge is not exclusive to France, as similar situation has been reported in other European settings, including Scandinavia, where training programs have demonstrated clinical value but have not yet resulted in widespread daily use among GPs [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study aims to assess the prevalence, modalities of use, and perceived impact of POCUS among GPs providing urgent medical serviceat a national level. It also explores how the tool is used (devices, indications, frequency), practitioners\u0026rsquo; perceptions, and barriers to broader adoption in this unique care setting.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy Design and Objectives\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe conducted a nationwide, cross-sectional, descriptive study between March 2025 and September 2025. The primary objective was to describe the prevalence of point-of-care ultrasound (POCUS) use among GPs working within the SOS M\u0026eacute;decins network in France. Secondary objectives included identifying the modalities of POCUS use, perceived barriers and facilitators, and the characteristics of practitioners using POCUS in routine practice.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthics\u003c/b\u003e\u003c/p\u003e\u003cp\u003e The study protocol was reviewed and approved by the Lyon University Hospital Ethics Committee (Comit\u0026eacute; d\u0026rsquo;\u0026Eacute;thique des Hospices Civils de Lyon \u0026ndash; IRB number 00014232). All participants were informed about the study objectives, data handling procedures, and their rights, including the option to withdraw at any time. Data were collected anonymously and handled in accordance with General Data Protection Regulation (GDPR).\u003c/p\u003e\u003cp\u003e\u003cb\u003eSetting and Population\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSOS M\u0026eacute;decins is a nationwide network of approximately 1,300 GPs providing 24/7 urgent and continuity of primary care in France, primarily through home visits. The study targeted all GPs actively practicing within the SOS M\u0026eacute;decins France network at the time of the survey.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSample Size\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe eligible population consisted of approximately 1,300 physicians. No a priori sample size calculation was performed, as no prior national data were available to inform a specific hypothesis of interest or expected response rate. Incomplete or clearly inconsistent responses were excluded from analysis.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAn anonymous, structured, self-administered questionnaire was developed based on existing literature and expert input. The survey comprised 37 items covering the following domains:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eDemographics and professional characteristics\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCurrent access to and use of POCUS\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eClinical indications and anatomical targets\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePerceived impact on clinical decision-making\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTraining history and learning needs\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBarriers and facilitators to POCUS adoption\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eSelection of clinical indications and anatomical targets was guided by international studies, ensuring comparability with prior research and enhancing generalizability [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe perceived impact of POCUS on patient management (including time-saving, diagnostic assistance, and therapeutic decision-making) was assessed using a 5-point Likert scale, as recommended in previous studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe questionnaire was built and distributed via a secure online platform (RedCap\u0026copy;) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePhysicians were first contacted by email via the national SOS M\u0026eacute;decins mailing list. Two reminder emails were sent at three-week intervals. Additionally, the study was presented at the SOS M\u0026eacute;decins national congress in June 2025, where a QR code was displayed to facilitate voluntary participation. Participation was voluntary and without financial compensation.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using SAS software, version 9.4 (SAS Institute Inc., Cary, NC, USA). Descriptive statistics were used to summarize participant characteristics and response distributions. Categorical variables were described by frequencies and percentages. Chi-square or Fisher\u0026rsquo;s exact tests were used for comparisons where relevant, with a significance threshold of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\n\u003ch3\u003e1. Population Characteristics\u003c/h3\u003e\n\u003cp\u003eGPs characteristics are provided in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Out of approximately 1,300 physicians contacted, 211 completed the questionnaire (16%): 110 non-users of point-of-care ultrasound (POCUS) and 101 current users. The majority were male in both groups (80.9% among non-users, 82.2% among users). Age distribution differed significantly between users and non-users (p\u0026thinsp;=\u0026thinsp;0.0208). POCUS users were mainly in mid‑career (35\u0026ndash;44 years; 43.6% vs. 30.9%), whereas non‑users were more often at the beginning (\u0026lt;\u0026thinsp;35 years; 20% vs. 14.9%) or end (\u0026ge;\u0026thinsp;65 years; 10.9% vs. 0.99%) of their career.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant characteristics by use of point-of-care ultrasound (POCUS) among SOS M\u0026eacute;decins physicians.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModality\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePOCUS users (n\u0026thinsp;=\u0026thinsp;101) N (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNon-users (n\u0026thinsp;=\u0026thinsp;110) N (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge group (years)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25\u0026ndash;34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (14.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e22 (20.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35\u0026ndash;44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44 (43.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e34 (30.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45\u0026ndash;54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (20.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21 (19.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55\u0026ndash;64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (19.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21 (19.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;65\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (0.99%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e12 (10.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.0208\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83 (83%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e89 (80.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (17%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21 (19.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.6943*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eYears in SOS practice (years)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (17.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e35 (31.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u0026ndash;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29 (28.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e17 (15.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u0026ndash;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (34.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25 (22.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (18.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e33 (30.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.0034\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePractice environment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e90 (89.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e100 (90.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.6626\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePeri-urban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (48.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e39 (35.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0,0546\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (13.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14 (12.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0,8083\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAccess to radiologist\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEasy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31 (30.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e43 (39.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60 (59.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e55 (50.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDifficult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (9.90%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e12 (10.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.3744\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eValues are presented as number (percentage). Comparisons between users and non-users were made using Chi-square or Fisher\u0026rsquo;s exact test where appropriate.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e* One participant selected \u0026lsquo;Other / No answer\u0026rsquo; for gender; this response was excluded from group comparison due to insufficient sample size.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eStatistically significant differences (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA significant difference was also observed regarding years of experience in SOS M\u0026eacute;decins (p\u0026thinsp;=\u0026thinsp;0.0034). Mid-career physicians (5\u0026ndash;20 years) were more likely to use POCUS (63.4%), while early-career and senior doctors were more represented among non-users (31.8% and 30.0%, respectively).\u003c/p\u003e\u003cp\u003ePractice settings were not different across groups, with most respondents working in urban or peri-urban areas (urban: approximatively 90% for both users and non-users; peri-urban: 35.5% non-users vs. 48.5% users). Access to radiologists was not significantly different (p\u0026thinsp;=\u0026thinsp;0.3744), with most describing it as moderate or difficult (non-users: 69.9%; users: 69.3%).\u003c/p\u003e\n\u003ch3\u003e2. Use and Non-Use of POCUS\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Current Users (n\u0026thinsp;=\u0026thinsp;101)\u003c/h2\u003e\u003cp\u003eMost users had been practicing POCUS for more than 5 years (37.5%), followed by 1\u0026ndash;3 years (32.3%) and 3\u0026ndash;5 years (21.9%). Daily use was reported by 41.1%, while 33.7% used it weekly. The majority (87.4%) reported performing focused scans for specific clinical indications, rather than general imaging.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Non-Users (n\u0026thinsp;=\u0026thinsp;110)\u003c/h2\u003e\u003cp\u003eNon-users accounted 52.1% of respondents. When asked whether specific training might encourage adoption, 54.5% responded affirmatively, 27.3% were unsure, and 18.2% indicated no interest.\u003c/p\u003e\u003cp\u003eFurther details on reported barriers to adoption, including perceived usefulness, time constraints, and access or equipment issues, are presented in section \u003cspan refid=\"Sec12\" class=\"InternalRef\"\u003e6\u003c/span\u003e (Barriers to Use and Training Gaps).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e3. Indications and Anatomical Targets\u003c/h3\u003e\n\u003cp\u003eAmong users, the most common indications for using POCUS were Abdominal pain (79.2%), Vascular assessments (76.2%), Respiratory symptoms (65.3%), Chest pain (33,7%), Trauma assessment (29,7%) and Musculoskeletal evaluation (22,8%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAdditional uses reported in open comments included bladder volume evaluation, gynecological indications (e.g. suspected ectopic pregnancy, ovarian cyst), as well as ocular, thyroid, and testicular assessments.\u003c/p\u003e\n\u003ch3\u003e4. Access to Equipment\u003c/h3\u003e\n\u003cp\u003e69,8% of POCUS users relied on portable ultrasound devices, while 12.5% used fixed devices and 17.7% reported using both. Access to equipment was not perceived as a major barrier: only 2.7% of non-users cited it explicitly.\u003c/p\u003e\u003cp\u003eThis contrast highlights a distinction between objective accessibility and subjective perception of cost as a barrier.\u003c/p\u003e\n\u003ch3\u003e5. Perceived Impact of POCUS\u003c/h3\u003e\n\u003cp\u003eThe perceived clinical value of POCUS was high among users across all assessed dimensions. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the majority of respondents rated its impact as positive or very positive on intellectual satisfaction (91.4%), patient triage (86.0%), diagnostic efficiency (67.0%), and treatment decisions (81.7%). The perceived impact on reducing additional testing was slightly lower (49.5%).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAdditionally, qualitative comments reinforced this favorable perception. For example, one participant described POCUS as \u0026ldquo;the stethoscope of the 21st century,\u0026rdquo; while another stated: \u0026ldquo;It has revolutionized my practice and decision-making processes.\u0026rdquo;\u003c/p\u003e\u003cp\u003eNotably, even among non-users, 57.3% rated the potential impact of POCUS as positive or very positive, indicating a strong underlying interest.\u003c/p\u003e\n\u003ch3\u003e6. Barriers to Use and Training Gaps\u003c/h3\u003e\n\u003cp\u003eAmong non-users, the main barriers included Lack of training (63.6%), Lack of time (44.5%), Equipment cost (40%) and Perceived low utility (23,6%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFree-text responses also highlighted recurring concerns about medico-legal uncertainties, technical proficiency, and the absence of billing incentives, all of which further discouraged adoption.\u003c/p\u003e\u003cp\u003eAmong users, 89.5% reported having some form of training, including a University or Inter-university Diploma in POCUS (22,8%), industry-sponsored sessions (15,8%), continuing medical education (61.4%), and self-directed learning (29,7%).\u003c/p\u003e\u003cp\u003eYet only 15,6% reported integrating POCUS into their billing practices.\u003c/p\u003e\n\u003ch3\u003e7. Suggestions and Open Comments\u003c/h3\u003e\n\u003cp\u003eApproximately one-quarter of respondents (25.1%, n\u0026thinsp;=\u0026thinsp;53) provided qualitative comments, offering rich insights into both clinical practice and system-level challenges.\u003c/p\u003e\u003cp\u003eSix major themes emerged:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eClinical utility and evolving standards\u003c/b\u003e: Several respondents described POCUS as \u0026ldquo;indispensable\u0026rdquo; or \u0026ldquo;revolutionary\u0026rdquo; in acute care contexts. Comments emphasized its role in ruling out life-threatening conditions, enhancing diagnostic speed, and improving outpatient triage: \u0026ldquo;It is the stethoscope of the 21st century.\u0026rdquo; \u0026ldquo;I can\u0026rsquo;t work without it anymore.\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eTraining needs and mentorship\u003c/b\u003e: Many called for structured, hands-on training pathways tailored to the SOS M\u0026eacute;decins context. Proposals included internal mentorship programs, partnerships with existing certified trainers, and echo-first initiatives modelled on local examples: \u0026ldquo;The best training I had was from fellow SOS physicians.\u0026rdquo; \u0026ldquo;Why not have internal training by experienced DU-certified colleagues?\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eInstitutional and financial recognition\u003c/b\u003e: A dominant theme was the demand for a dedicated billing code, analogous to those available for electrocardiography (ECG), and better guidance regarding the French medical classification system for procedures and billing (Classification Commune des Actes M\u0026eacute;dicaux- CCAM): \"A specific billing code would recognize the time, cost and skill invested.\" \"We need clearer guidelines on how to code ultrasound procedures.\"\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eEquipment costs and technical barriers\u003c/b\u003e: Respondents frequently cited the high cost of quality devices and the difficulty of fitting scans into short home visits. \u0026ldquo;If only performant machines weren\u0026rsquo;t so expensive.\u0026rdquo; \u0026ldquo;Adds 15\u0026thinsp;+\u0026thinsp;minutes per consultation, hard to manage in urgent care.\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eProfessional identity and patient rapport\u003c/b\u003e: Several comments highlighted how POCUS reinforces clinical credibility, fosters patient trust, and preserves GPs\u0026rsquo; central role in a shifting care landscape: \u0026ldquo;It boosts patient trust and strengthens the doctor-patient bond.\u0026rdquo; \u0026ldquo;We must stay central in the system. POCUS helps us remain indispensable.\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eStrategic vision for the future\u003c/b\u003e: Beyond individual practice, a number of respondents emphasized the need for a national strategy, equipment supports from the network, and a shared vision for integrating POCUS sustainably in out-of-hospital care. \u0026ldquo;POCUS is a necessity, not an option.\u0026rdquo; \u0026ldquo;SOS should actively promote training and access for all.\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"Discussions","content":"\n\u003ch3\u003e1. Principal findings\u003c/h3\u003e\n\u003cp\u003e This national survey provides the first quantification of point-of-care ultrasound (POCUS) use among GPs working within SOS M\u0026eacute;decins, a nationwide network delivering urgent and continuity of primary care in France. Nearly half of the respondents (47.4%) reported using POCUS in their current practice. POCUS adoption was lowest among the youngest and oldest physicians, and highest in intermediate age groups\u0026mdash;particularly among those aged 36 to 55. Among users, the tool was primarily employed for the evaluation of acute abdominal pain, vascular assessments and respiratory symptoms. Most used portable devices and performed targeted exams based on specific clinical suspicions.\u003c/p\u003e\u003cp\u003eNon-users, who represent 52.6% of the sample, primarily cited lack of specific training, time constraints during consultations, and the cost of equipment cost as key barriers. Notably, more than half of the non-users expressed interest in POCUS training.\u003c/p\u003e\u003cp\u003eThese findings highlight both the advanced stage of informal diffusion of POCUS into frontline urgent general practice and the structural constraints that still limit its broader and safer integration.\u003c/p\u003e\u003cp\u003eIn both user and non-user groups, the lack of financial recognition was a recurring concern. Many users reported not billing the act due to the absence of a dedicated code, while some non-users highlighted the inability to valorize the act financially as a disincentive. This underscores a systemic gap between clinical practice and the current regulatory and billing framework in France.\u003c/p\u003e\n\u003ch3\u003e2. Comparison with existing literature\u003c/h3\u003e\n\u003cp\u003e The 47.4% adoption rate observed in our study ranks among the highest reported in primary care settings internationally. In Denmark, a recent national survey found that 11.5% of GPs reported active POCUS use [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. While the methodological contexts differ, particularly regarding response rates, this comparison highlights the notable diffusion of POCUS within the SOS M\u0026eacute;decins network. In Hong Kong, a cross-sectional evaluation of primary care physicians reported a prevalence of 22.5% [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Switzerland, a nationwide study combining billing data and survey responses found that 49% of general practitioners had billed at least one ultrasound examination between 2004 and 2018. While this figure does not reflect regular or systematic use, the authors reported a steady increase in the number of users and procedures over time, suggesting a progressive diffusion of ultrasound into primary care settings [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. More recently, Zumstein et al. (2024) found that 56.5% of Swiss GPs owned an ultrasound device, and 77% of reported scans were self-performed, particularly in rural or urgent care settings, underscoring the relevance of POCUS in areas with limited access to diagnostic imaging [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough few international studies provide precise or methodologically comparable prevalence, several investigations support the growing integration of POCUS in primary care. Kornelsen et al. reported frequent use and positive experience with POCUS among rural family physicians in British Columbia, Canada, underlining its relevance in remote or resource‑limited settings [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. By contrast, our findings suggest more limited uptake in rural zones within the French context. Despite an overall adoption rate of 47.4%, only 13,9% of users in our study practiced in rural areas, indicating that access to POCUS may still be unequal depending on geographic context. This result should be interpreted in light of the fact that SOS M\u0026eacute;decins operates predominantly in urban and peri-urban areas, which partly explains the low percentage of rural practitioners in our sample. This disparity nonetheless underscores the need for targeted implementation strategies in underserved or resource-limited regions.\u003c/p\u003e\u003cp\u003eIn Norway, Myklestul et al. analysed national health‑insurance reimbursement data and found that the number of GPs performing POCUS increased from 479 in 2009 to 2 078 in 2016; the number of registered scans rose from 8 962 to 55 921 over the same period. By 2016, about 30% of Norwegian GPs had billed for POCUS, although three out of four scanning GPs performed fewer than 10 scans per year [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur finding of a U-shaped distribution in POCUS use\u0026mdash;with the lowest adoption among the youngest and oldest physicians, and the highest among those aged 36 to 55\u0026mdash;may reflect generational differences in exposure and training. This trend aligns only partially with international observations. In the United States, a national survey among family medicine residents, faculty, and graduates found that while 95.6% of respondents considered POCUS important in family medicine, only 5.4% reported feeling extremely comfortable using it. Notably, residents (younger physicians) were more comfortable and had significantly more prior POCUS training than faculty and graduates, who are likely to include older physicians. This supports the hypothesis that many senior doctors were trained before ultrasound became part of family medicine curricula, leading to a persistent training gap [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Conversely, among younger physicians, interest in POCUS appears to grow as clinical experience accumulates. A recent Hungarian study showed that newly graduated GPs were motivated to integrate ultrasound into practice as a way to enhance diagnostic autonomy and clinical confidence. However, 59.5% acknowledged limited familiarity with its indications and use, suggesting that low early-career adoption may be more a matter of opportunity than reluctance [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Together, these findings support our interpretation of a generational gradient in exposure and training, rather than intrinsic resistance based on age.\u003c/p\u003e\u003cp\u003eBarriers identified in our study, training gaps, lack of time, and cost, mirror those noted in multiple international investigations. In a U.S. primary care\u0026ndash;oriented survey, Nathanson et al. (2023) found that lack of trained providers, equipment cost, and limited funding for training were the most common obstacles [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In Australia, Arnold et al. (2023) reported similar challenges, including high device cost and difficulties in recouping expenses through reimbursement [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Yamada et al. (2024) further documented that nearly half of physicians cited limited training opportunities and access to ultrasound machines as key barriers [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Even in hospital-based settings, Resop et al. (2025) observed consistent constraints across specialties, particularly regarding training and infrastructure support [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn terms of training, our findings are consistent with those of Ben Shitrit et al. (2025), who demonstrated in a pre-post design that a focused abdominal POCUS training program significantly improved primary care physicians\u0026rsquo; skills, confidence, and frequency of use [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSimilarly, Andersen et al. (2022) explored how Danish GPs strive to acquire ultrasound skills, emphasizing the role of self-directed learning and peer-to-peer mentorship in the absence of formalized training frameworks [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn France, emergency physicians have developed structured POCUS training pathways and defined minimum skill standards, as outlined in their national competency framework [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. This formalization has contributed to broader and safer integration within their specialty. By contrast, general practice training still lacks mandatory ultrasound teaching, leaving most young GPs untrained upon graduation. Continuing education, though essential, cannot replace a structured initial curriculum tailored to primary care needs.\u003c/p\u003e\u003cp\u003eMoreover, our observation that many respondents use POCUS without formal recognition or reimbursement resonates with the notion of informal or \u0026ldquo;hidden integration\u0026rdquo; of POCUS seen in European general practice settings, as discussed in the systematic review by Sorensen et al. [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003e3. Strengths and limitations\u003c/h3\u003e\n\u003cp\u003eThis is the first national-level study to investigate both the prevalence and practical modalities of POCUS use among GPs working in French urgent primary care. Its main strengths include the inclusion of both users and non-users, the analysis of perceived barriers, impact, and training needs, as well as the study\u0026rsquo;s national scope. The population was clearly defined, focusing exclusively on GPs working within the SOS M\u0026eacute;decins network, which ensures homogeneity in practice context and enhances the interpretability of findings within urgent primary care.\u003c/p\u003e\u003cp\u003eLimitations include the response rate (16%), which may raise concerns regarding potential selection bias, particularly the risk of overrepresentation of physicians already interested in ultrasound. However, this bias appears limited. The nearly equal distribution between users (47,4%) and non-users (52,6%) suggests no major differential response. Additionally, key demographic variables (age, gender, experience) were broadly distributed. Promotion through multiple channels, including a national congress, further supports the diversity of the sample. While the response rate remains modest, the internal balance supports the credibility of the findings. Still, we acknowledge that this participation rate limits the generalizability of our findings to all SOS M\u0026eacute;decins physicians or to GPs in family medicine. Because some survey questions allowed multiple answers, certain reported frequencies may overlap, and total percentages may exceed 100%. The study also highlights a regulatory grey area, as several respondents reported using POCUS routinely without access to formal training pathways, institutional validation mechanisms, or dedicated billing frameworks. In France, there is currently no requirement for GPs to hold a specific certification to conduct ultrasound examinations, as long as they consider themselves competent and can justify it in case of litigation, in line with current medico-legal standards. This situation is comparable to other procedures commonly used in primary care, such as ECG, which are often self-taught and performed without formal accreditation.\u003c/p\u003e\n\u003ch3\u003e4. Implications and future directions\u003c/h3\u003e\n\u003cp\u003ePOCUS appears increasingly embedded in the diagnostic routines of urgent primary care GPs in France. The strong adoption rate of POCUS, combined with the high level of interest in further training among both users and non-users, underscores its perceived value and relevance.\u003c/p\u003e\u003cp\u003eTo support safe and sustainable integration of POCUS in primary care, future initiatives should focus on the following complementary levels of action:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDeveloping structured undergraduate training and defining core competencies for general practitioners.\u003c/b\u003e Integrating ultrasound education into early medical training is essential to prepare future GPs for the evolving scope of clinical practice. National curricula should clearly define the competencies relevant to general practice and be informed by robust evidence on the utility and safety of POCUS in unselected primary care populations [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].;\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eExpanding continuing medical education opportunities for practicing GPs\u003c/b\u003e. Short-format, high-yield training programs focused on common and high-impact indications (e.g. abdominal pain, dyspnea, trauma) have shown strong potential to improve diagnostic confidence and clinical decision-making in primary care contexts [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. These should be made more widely accessible and standardized.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eFostering local initiatives within the SOS M\u0026eacute;decins network.\u003c/b\u003e Internal training, structured mentorship, and collaborative image review activities\u0026mdash;whether formal or peer-led\u0026mdash;can support the development and maintenance of skills. Such initiatives could be implemented both locally (within each association) and nationally to build a shared culture of quality and safety.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eEnhancing financial and administrative recognition.\u003c/b\u003e Administrative barriers remain significant. Improving awareness of existing billing codes and advocating for clearer, dedicated reimbursement mechanisms are essential to ensure equitable access and long-term integration [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eFurther studies are needed to assess the clinical and cost-effectiveness of POCUS in French primary care, including its effects on referral rates, diagnostic delay, and patient outcomes. Implementation research should also explore the feasibility of regional mentorship networks or hospital-GP collaborations to foster real-time learning and quality control, as suggested by prior studies linking POCUS to reduced diagnostic uncertainty and healthcare utilization [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough this study focused on GPs working in urgent and unscheduled care, its findings raise broader questions about the potential use of POCUS in family medicine. Several facilitating factors identified here, such as perceived diagnostic value, clinical autonomy, and professional satisfaction, are likely shared by GPs in family medicine. In the context of growing medical deserts, where access to specialist consultations or imaging facilities is often limited, POCUS could play a valuable role in enhancing diagnostic equity and reducing avoidable delays.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis national survey provides the first detailed insight into the use of POCUS among general practitioners working in urgent primary care within the SOS M\u0026eacute;decins network. With an adoption rate of 47.4% among respondents, our findings highlight a substantial but heterogeneous uptake, particularly influenced by physician age, training background, and access to equipment.\u003c/p\u003e\u003cp\u003eWhile the overall response rate (16%) limits generalizability, the balanced representation of both users and non-users suggests that these results offer a credible reflection of current trends and perceptions within this unique out-of-hospital care model. The strong training demand among non-users and the positive perceptions reported by users indicate a clear momentum toward broader and safer integration of POCUS in French primary care.\u003c/p\u003e\u003cp\u003ePolicymakers and professional bodies should now focus on developing and structuring undergraduate POCUS education within medical schools, expanding accessible continuing training programs, improving awareness and usability of existing billing pathways, establishing appropriate reimbursement frameworks, and fostering local mentorship initiatives to ensure safe and sustainable implementation.\u003c/p\u003e\u003cp\u003eFurther research should evaluate the clinical and economic impact of POCUS in primary care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eGDPR: General Data Protection Regulation\u003c/p\u003e\n\u003cp\u003eGP: General practitioners\u003c/p\u003e\n\u003cp\u003ePOCUS: Point-of-care ultrasound\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Lyon University Hospital Ethics Committee confirmed that this study did not fall within the scope of French Jardé law[37] and therefore did not require the consent of participants. However, all procedures performed in this study were in accordance with the 1964 Helsinki Declaration\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDeidentified data may be available in French from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePB is a member of the scientific committee of SOS Médecins. The other authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have contributed substantially to this work and meet criteria for authorship as stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals, and each authors’ contribution is listed below:\u003c/p\u003e\n\u003cp\u003eStudy concept and design: NB, PB, JB, AMS\u003c/p\u003e\n\u003cp\u003eAcquisition of data: PR, NB\u003c/p\u003e\n\u003cp\u003eAnalysis and interpretation of data: TH, NB\u003c/p\u003e\n\u003cp\u003eDrafting of the manuscript: NB, PB\u003c/p\u003e\n\u003cp\u003eCritical revision of the manuscript for important intellectual content: all authors\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved this final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all the GPs who responded to the questionnaire.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAli N, Soomar SM, Waheed S. 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Anaesth Crit Care Pain Med. 2018;37:607\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.accpm.2018.10.013\u003c/span\u003e\u003cspan address=\"10.1016/j.accpm.2018.10.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Point-of-care ultrasound, POCUS, prevalence, general practice, primary care, urgent care, France, SOS Médecins","lastPublishedDoi":"10.21203/rs.3.rs-7943149/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7943149/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003ePoint-of-care ultrasound (POCUS) is increasingly recognized as a valuable diagnostic tool in general practice. However, its actual use among French general practitioners (GPs) working in urgent care settings, such as SOS M\u0026eacute;decins, a nationwide network of GPs providing home-based urgent primary care 24/7, remains poorly documented.\u003c/p\u003e\u003ch2\u003eObjectives:\u003c/h2\u003e\u003cp\u003eTo assess the prevalence, modalities of use, perceived impact, and barriers to the adoption of POCUS among GPs working in the SOS M\u0026eacute;decins network across France.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eA national cross-sectional online survey was distributed to all eligible SOS M\u0026eacute;decins physicians. The questionnaire addressed POCUS usage, clinical indications, equipment access, perceived benefits, training needs, and adoption barriers. Descriptive statistics were used, and comparisons between users and non-users were performed using chi-square or Fisher\u0026rsquo;s exact tests.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eAmong 211 respondents, 47.4% reported current POCUS use. Statistically significant differences between users and non-users were observed for age group (p\u0026thinsp;=\u0026thinsp;0.0208) and years of experience in SOS M\u0026eacute;decins (p\u0026thinsp;=\u0026thinsp;0.0034). The most frequent indications included abdominal pain (79.2%), vascular assessment (76.2%), and respiratory symptoms (65.3%). Most users relied on portable devices (69.8%) and performed focused, indication‑driven scans (87.4%). POCUS was perceived as having a positive or very positive impact on triage (86.0%), treatment decisions (81.7%), diagnostic accuracy (67.0%), professional autonomy (59.0%), and the doctor\u0026ndash;patient relationship (50.0%). Nevertheless, only 15.6% of users reported billing for POCUS acts. Among non-users, the main barriers were lack of specific training (63.6%), limited time (44.5%), equipment cost (40%), and doubts about clinical utility (23.6%). More than half (54.5%) expressed interest in receiving training.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003e POCUS is currently used by nearly half of SOS M\u0026eacute;decins physicians providing urgent primary care in France. Despite strong clinical interest and perceived utility, adoption remains limited by training gaps, structural barriers, and lack of clear financial incentives.\u003c/p\u003e","manuscriptTitle":"Use of point-of-care ultrasound (POCUS) in French urgent primary care: a national survey of general practitioners in the SOS Médecins network","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-10 16:23:03","doi":"10.21203/rs.3.rs-7943149/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-13T17:20:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-12T07:54:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"322103692760316398359028965334689723139","date":"2025-12-17T17:21:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-05T18:47:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201821531633316820076459166173871478726","date":"2025-11-12T16:50:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-30T12:28:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-27T17:13:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-27T03:45:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-27T03:43:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-10-24T20:03:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"df367c8e-a9ee-41d1-83d7-513998ce3c7f","owner":[],"postedDate":"November 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T12:09:47+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-10 16:23:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7943149","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7943149","identity":"rs-7943149","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}