Cite as: Sen S, Baumann N, George R. POCUS spotlight: defining competency in point of care ultrasound. ASRA Pain Medicine News 2025;50. https://doi.org/10.52211/asra110125.011.

POCUS Spotlight

Introduction

At some point, we all hear the well-worn adage, “You want an old lawyer and a young doctor,” which highlights the distinction in value that each profession places on experience vs. innovation. In his paper addressing the challenges facing medical education, Peter Densen wrote,” Knowledge is expanding faster than our ability to assimilate and apply it effectively.”¹ Our field has seen a rapid expansion of knowledge, interest, and innovation in the last decade, supported by technology and artificial intelligence.

In the not-too-distant future, our learners may surpass us in knowledge and skills; yet we still carry the responsibility of their education. Point-of-Care Ultrasound (POCUS) is increasingly integrated into medical practice across multiple specialties, given its varied and real-time capabilities. The role of POCUS in clinical care and the need for POCUS education as a part of residency training have been recognized.² “A key aspect to the success of a training sequence for POCUS also relates to the skill and motivation of the faculty, particularly with regard to hands-on training,” and requires clear definitions of competency of newly acquired skills.³

Traditionally, training emphasized scan volume as a surrogate for proficiency; however, emerging evidence advocates for a competency-based approach that accounts for skill acquisition, image interpretation, and clinical integration.^4,5 The American College of Emergency Physicians (ACEP) and the Accreditation Council for Graduate Medical Education recommend 150–300 total POCUS scans, with 25–50 scans per core application area (eg, FAST, cardiac, lung). Observed structured clinical examinations (OSCEs) and direct faculty assessments are increasingly used for evaluating image acquisition, interpretation, and clinical reasoning.^6,7 Scan numbers correlate with OSCE performance, but a plateau in improvement often appears after 300 scans.⁷

Learning encompasses both cognitive understanding and psychomotor skills rather than image acquisition alone. Achieving proficiency requires more than repeated attempts; it involves simulation-based training and longitudinal, deliberate practice.⁸ “Ideally, competency is based on multiple observations and in a variety of clinical scenarios,” but this approach can be challenging given the clinical and time limitations.⁹

The Importance of Perceptual Learning and Numerical Targets

Perceptual learning or “experience-induced improvements” has been shown to improve the acquisition of expertise.¹⁰ It assesses prior knowledge and learning curves to set individualized target goals to obtain mastery of a topic or skill. The American Heart Association has incorporated this concept to increase efficiency and improve outcomes.¹¹ Our specialty is unique in that “previous experience … [may contribute] to the lower number of scans required to achieve competence” for regional anesthesiologists, given our unique relationship with the ultrasound when compared to other specialties.¹² Perceptual learning makes it possible to set numerical goals that account for specialty-specific skills and knowledge, while still offering a common and practical approach for training programs due to its simplicity and ease of implementation. The numerical goal provided is suggested scan targets based on multi-specialty learning curves and requirements while still considering individual expertise and mastery.

Focused Assessment with Sonography for Trauma

Focused assessment with sonography for trauma (FAST) is a foundational ultrasound skill and is typically among the first taught to emergency medicine, anesthesiology, and critical care trainees. Multiple studies agree that performing between 25 to 50 supervised FAST scans allows learners to develop core skills, including image acquisition and anatomic recognition.¹³ Beyond this initial range, performance continues to improve with several studies suggesting that strong proficiency is often observed after approximately 79 FAST exams.⁷

Evaluation of Learning Curves

In a controlled study of peritoneal dialysis patients, providers with greater clinical FAST experience (defined as >100 scans) demonstrated higher sensitivity and greater accuracy in fluid detection than those with moderate (30–100) or minimal (<30) experience. This suggests that while technical proficiency may begin to emerge after ~30 scans, the learning curve flattens and plateaus between 30–100 examinations.¹⁴

Despite these numerical thresholds, emerging literature emphasizes that competency is better assessed by performance metrics than by scan counts alone. Simulation-based mastery learning has proven to be a powerful adjunct with learners achieving competence in FAST after just two to four sessions, each lasting roughly 2 hours. However, significant variation in learning curves was noted, reinforcing the concept that training should be tailored to the learner rather than standardized based on volume alone.⁸

Succar et al. highlight the limitations of using scan count and speed as proxies for competence, showing that only 20% of 93 trainee-performed FAST exams yielded diagnostic-quality images across all four standard windows (pericardial, hepatorenal, splenorenal, and pelvic). To better evaluate performance, they applied two structured tools, the task-specific checklist (TSC), which scores completion of 24 anatomic landmarks and incorporates a Likert scale for image quality, and trauma video review (TVR), which allows objective assessment of FAST performance in real-world trauma resuscitations. Together, TSC and TVR provide a more reliable, performance-based measure of FAST competency by capturing both completeness and diagnostic quality of scans.¹⁵

Suggested Benchmarks for Competency

To more objectively evaluate skill, researchers have employed quantitative motion analysis, assessing probe path length, total scan time, and capture of defined anatomical targets.¹⁵ These studies consistently show that proficient users scan more efficiently and accurately than novices.¹³ Additionally, validated scoring systems like the Quality of Ultrasound Imaging and Competence score, which combines a TSC with a Global Rating Scale (GRS), have been developed to differentiate between novice and expert performers in both educational and clinical settings.¹⁶ TSCs in this study provided a binary assessment of whether individual steps within a complex task are completed, assigning a score of 1 for task completion and 0 for failure. In contrast, the GRS evaluates the overall quality of task performance on a Likert scale, focusing on how well each component (eg, a scan) is performed rather than simply whether it was completed.

The ASRA Pain Medicine expert panel on POCUS education and training for regional anesthesiologists and pain physicians and the American Society of Anesthesiology (ASA) Ad Hoc Committee propose a standardized competency structure using Level 1 and Level 2 classifications.⁴

Level 1 studies: Supervised scans that are personally performed and interpreted by the learner.

Level 2 studies: Supervised interpretations of scans not necessarily performed by the learner, allowing for computer-based or case review learning.

In alignment with existing evidence, several professional societies have established minimum scan requirements for achieving competency in the FAST examination. The ACEP recommends completion of 25–50 supervised FAST exams. The Society of Critical Care Medicine (SCCM) advises 20 “Level 1” and 10 “Level 2” exams, while the Canadian Critical Care Society (CCCS) suggests 10 “Level 1” exams.⁴ Based on the best available data and expert consensus, the ASRA Pain Medicine expert panel on POCUS education and training for regional anesthesiologists and pain physicians recommends a total of 50 exams for basic competency which must include 30 Level 1 FAST exams and 20 Level 2 FAST exams.⁴

Perceptual learning or “experience-induced improvements” has been shown to improve the acquisition of expertise. It assesses prior knowledge and learning curves to set individualized target goals to obtain mastery of a topic or skill.

Lung Ultrasound

Lung Ultrasound (LUS) is an integral part of the extended FAST exam and is used in emergency, critical care, and perioperative settings for the diagnosis of life-threatening conditions, such as pneumothorax, pleural effusion, interstitial syndromes, and consolidation. Importantly, LUS images have high accuracy, greater than chest radiographs and approaching chest computed tomography, without introducing radiation.¹⁷ As LUS becomes a routine tool, it is vital for structured training with clear competency benchmarks to be integrated into clinical care.

Competency in LUS requires accurate and consistent interpretation and image acquisition. Prior studies on sonographers' experience with LUS impacting diagnostic accuracy of pneumonia in children have emphasized the importance of achieving high interobserver agreement in identifying lung pathology, supported by validated visual indicators, such as hepatization, pleural effusions, or B lines due to alveolar-interstitial syndrome.¹⁸ As with FAST, these findings underscore the need for a standardized curriculum that incorporates a defined number of supervised scans and a post-test administered by ultrasound experts.¹⁸

Evaluation of Learning Curves

Russell et al. conducted a study to identify the minimum requirements for quantifying B-lines in LUS with proficiency. After a LUS training session on B-line assessment, trainees attempted to quantify B-lines in patients with acute heart failure. Trainee B-line counts were blindly reviewed by five United States fellowship-trained faculty with > 5 years of clinical experience, and proficiency was defined as an intraclass correlation of > 0.7. The investigators found that novice trainees achieved proficiency for quantifying B lines after scanning 11 zones on LUS. There was no significant difference in the number of scanned zones required to reach proficiency between physicians and non-physicians (P = 0.26), trainees with no prior LUS experience vs. trainees with > 25 prior patient scans (P = 0.64) and no prior vs. some prior LUS experience (P = 0.59). This study defines the baseline training required to achieve the desired proficiency in both physician and non-physician trainees.¹⁹

Additionally, House et al. conducted an 8-hour LUS training session and evaluated physician proficiency in a low-resource setting. They found that physicians reached proficiency in interpreting LUS, compared with experts, after 4.4 (SD 2.2) LUS studies in individual-zone interpretation and 4.8 (SD 2.3) studies for overall interpretation.²⁰

A multicenter study by Arbelot et al. evaluated learners using LUS to analyze 7,330 lung regions in 2,562 critically ill and emergency patients. The study included a 2-hour didactic video session covering lung patterns. Trainees correctly identified 80% of lung regions after 25 supervised examinations and 93% after 30 supervised examinations. Median time required to perform a complete LUS examination among trainees decreased from 19 minutes to 12 minutes after 5 and 25 supervised examinations, respectively. The median training duration was 52 days. ²¹

The American Institute of Ultrasound in Medicine (AIUM) published updated guidelines on the use of lung ultrasound. They state that training should include hands-on learning guided by experts as well as analysis of case reviews related to pulmonary pathophysiology. Real-world applications of LUS are the assessment of multiple disease states, including pneumothorax, pulmonary edema, pleural effusion, and pneumonia. LUS can also be useful for understanding hemodynamics and alveolar recruitment maneuvers. Additionally, LUS should be included in ongoing medical education, either through traditional classroom instruction or e-learning.²²

Suggested Benchmarks for Competency

Based on the updated AIUM guidelines and the study by Arbelot et al., to achieve baseline competency in LUS, trainees must be able to classify lung zones, perform timely scans, interpret normal lung findings, and recognize specific lung pathologies. Continued medical education is highly encouraged even after baseline competence is achieved.^21,22

ACEP advises 25–50 supervised Level 1 LUS examinations to achieve competency. SCCM recommends 20 Level 1 plus 10 Level 2 LUS examinations, while the CCCS advises 20 Level 1 LUS examinations. Drawing on both published evidence and these society guidelines, the ASRA Pain Medicine expert panel on POCUS education for regional anesthesiologists and pain physicians recommends completion of 30 Level 1 and 20 Level 2 LUS examinations to establish competency.⁴

Focused Cardiac Ultrasound

Focused cardiac ultrasound (FoCUS), when used as part of POCUS, is an invaluable tool for anesthesiologists, as it can facilitate earlier interventions in life-threatening conditions due to its diagnostic accuracy.³ To maximize its potential and ensure safe and effective use, it is imperative that standardized training with formal competency assessments is used. Competency in FoCUS is designated on the level of training with the American College of Cardiology Level 1 [MKK1] correlating most closely with POCUS competency requirements.^23,24

Level 1: Introductory or early level of competency in performing and interpreting transthoracic echocardiography. Answer a specific clinical question, but not sufficient for independent interpretation of echocardiography.

Level 2: Additional training allowing performance and interpretation of specialized procedures. Usually acquired during fellowship.

Level 3: Required for performance and interpretations of complex studies in special populations, lead research, or directing an echo lab.

Evaluation of Learning Curves

Multiple factors shape the learning curve for FoCUS, including baseline ultrasound experience, practice frequency, the quality of feedback received, and patient-related variables, such as altered anatomy, obesity, or positioning, which may influence the consistency of image acquisition. Access to simulation further enhances skill development.

While scan volume plays a role, it represents only one aspect of achieving competency. Professional societies vary widely in their requirements, ranging from 25 to 150 examinations. For example, the National Board of Echocardiography requires 150 examinations to be both performed and interpreted, whereas the ACEP recommends 25–50 examinations in each domain. The American College of Echocardiography recommends 75 examinations performed and 150 interpreted, while the SCCM recommends 30 examinations performed and a total of 50 interpreted. Similarly, the ASA requires 50 focused cardiac ultrasounds, and the European Society of Intensive Care Medicine recommends 30 supervised examinations. ^25,26 The British Society of Echocardiography Level 1 accreditation in adults highlights that while basic image acquisition skills may be achieved after approximately 20–30 scans, true competency, defined as accurate image interpretation that informs clinical decision making, requires at least 50–75 supervised examinations. In addition to an image interpretation assessment, candidates must maintain a logbook that reflects the case mix of acutely unwell patients and ensures adequate exposure to key pathologies. This includes a minimum of five cases each of impaired left and right ventricular systolic function, three cases each of aortic, mitral, and tricuspid valve disease; three cases of hypovolemia, two cases of pericardial effusion, and one case of aortic root dilatation with no more than 20 cases representing no significant abnormality. This structured approach underscores that competency in echocardiography is not defined by scan numbers alone but by deliberate practice across diverse pathologies with demonstrated interpretive accuracy.²⁷

Suggested Benchmarks for Competency

FoCUS proficiency tends to progress more slowly due to the complexity of image acquisition, particularly with variable patient anatomy, including rib shadowing and pleural interference. Most societies with expertise in cardiac ultrasound recommend between 25 and 150 exams in combination with didactics and expert feedback as well as consistent practice on a varied clinical case load. The ASRA Pain Medicine expert panel on POCUS education for regional anesthesiologists and pain physicians recommends 50 Level 1 FoCUS exams and 100 Level 2 exams for an anesthesiologist with no prior experience in FoCUS.⁴

Gastric Ultrasound

Gastric ultrasound has emerged as a valuable tool in assessing perioperative aspiration risk, particularly in high-risk populations such as those using Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RA) or presenting for emergency surgery. As its clinical adoption grows, standardized training and competency benchmarks are essential, especially for anesthesiologists integrating this into preoperative assessments.

Evaluation of Learning Curves

Arzola et al. conducted a study to determine the number of scans required for anesthesiologists to achieve competency in qualitative gastric ultrasound.⁶ After a structured educational program including didactic materials, image libraries, and supervised hands-on scanning, the investigators used cumulative sum analysis to evaluate performance. Competency, defined as a 90% diagnostic success rate was reached after an average of 24 scans. Furthermore, a predictive model estimated 33 scans were needed to achieve a 95% success rate. Solid content was most reliably diagnosed, while an empty stomach was the most difficult. This study, though limited to healthy volunteers, provided a rigorous baseline for structured qualitative assessment skill acquisition.⁶

Training should begin with didactics covering anatomy, clinical indications, limitations, and scanning technique followed by hands-on practice emphasizing image acquisition in both supine and right lateral decubitus positions. Learners must develop the ability to distinguish between an empty stomach, clear fluid, thick fluid, and solids, and to estimate gastric volume using cross-sectional area measurements.

Filipovic et al. expanded on these findings by analyzing 2,003 scans performed in a real-world setting by 73 anesthesiologists who had completed a structured training program requiring ≥30 supervised scans. A median performance time of 5 minutes was achieved after 20–27 additional independent scans, suggesting that ~50 scans are needed to reach real-world proficiency. Male sex, higher BMI, emergency and trauma surgery, and ASA III–IV status were independently associated with increased scan difficulty and algorithm deviations. Even after structured training, nearly 9% of scans required deviation from the standard scanning protocol. The study also confirmed that patient-related factors, especially the inability to assume the right lateral decubitus position, accounted for most challenges in algorithm adherence.²⁸

Suggested Benchmarks for Competency

The ASRA Pain Medicine expert panel on POCUS education for regional anesthesiologists and pain physicians recommends a minimum of 30 supervised Level 1 and 20 interpreted Level 2 gastric ultrasound studies, totaling 50 scans. Scan numbers alone are insufficient; structured assessments and observation of clinical decision-making are necessary. Simulation is not recommended due to the unique variability of gastric anatomy and content, and practice on live models is encouraged. These recommendations are meant to ensure safe, consistent use of gastric ultrasound in perioperative risk assessment.^4,5

Airway Ultrasound

Airway ultrasound has gained increased attention in recent years, providing the opportunity to assess patient airway anatomy, including the cricothyroid membrane (CTM), before manipulating difficult airways. While it cannot provide the same level of detail as other imaging modalities, like computed tomography (CT) or magnetic resonance imaging (MRI), it also does not expose the patient to radiation, nor is it as invasive as direct laryngoscopy for visualization. Airway POCUS also has the advantages of portability and real-time imaging compared to CT and MRI, making it much more accessible to clinicians.

Evaluation of Learning Curves

Oliviera et al. showed that trainees with limited experience and 2 hours of didactics in airway ultrasound could achieve competence in identifying the CTM in less than 20 scans, indicating a shorter learning curve.²⁹ A similar short learning curve was demonstrated in another study, in which ER physicians had to identify tracheal vs esophageal intubation and did so after a brief online tutorial and 2 practice attempts.³⁰Like other POCUS exams, prior ultrasound experience, patient variability, simulation-based training, and expert feedback played a vital role in identifying relevant airway anatomy.

In a feasibility study involving 22 healthy volunteer operating room staff members, trainees underwent a single-day course on a predefined upper airway ultrasound scanning protocol. The protocol emphasized identification of critical structures, including the hyoid bone, vocal cords, thyrohyoid membrane/epiglottis/pre-epiglottic space, cricothyroid membrane, and thyroid gland as well as specific measurements, such as the distance from the hyoid bone, anterior commissure, epiglottis, and thyroid isthmus to the skin surface. Competence was evaluated through multiple scanning repetitions performed over 1 week with mixed-effects regression models used to compare trainee and instructor measurements. The cricothyroid membrane proved most challenging with a visualization success rate of 88%. Overall, 10 or fewer scanning repetitions were sufficient to minimize measurement deviation across all parameters, supporting the use of at least 10repetitions of a standardized upper airway ultrasound protocol as a minimum training standard.³¹ While another study suggests that competence may be achieved with fewer scans, the authors only looked at whether trainees could identify the cricothyroid membrane and if the esophagus had been intubated.³²Conversely Clunie et al. were unable to achieve competency with eight supervised scans despite previous recommendations requiring only five scans for competency.¹²

Suggested Competency Benchmarks

As the learning curve for airway ultrasound is steep in certain areas, such as identifying the CTM and confirming esophageal intubation, and more variable in others, a comprehensive and structured training approach is essential. This should include didactic instruction, a thorough anatomical review of airway ultrasound, the use of standardized protocols to identify key structures, and the application of a complete upper airway protocol with multiple landmark identifications. Trainees should also engage in independent practice with limited supervision to reinforce skills. To guide competency development, the ASRA Pain Medicine expert panel on POCUS education for regional anesthesiologists and pain physicians recommends that airway ultrasound naïve anesthesiologists complete a minimum of 30 supervised Level 1 airway examinations and 20 Level 2 examinations.⁴

Pathways to Competency and Certification in POCUS

Achieving certification in diagnostic POCUS requires a substantial investment of time and structured training across multiple components. The ASA offers a five-part POCUS certification program. The process includes an optional quality improvement (QI) action plan. Evidence of prior diagnostic POCUS training through CME courses, NBE recognition, or residency/fellowship documentation is a prerequisite. Image interpretation skills are then developed through online, case-based modules. Image acquisition training involves building a portfolio of diagnostic POCUS studies, which must then be reviewed and approved by a mentor. Finally, candidates complete a 2-hour exam to earn their certificate of completion. Altogether, the pathway reflects a significant but deliberate investment in both time and training to ensure competency in diagnostic POCUS. This certification offers up to 60 AMA PRA Category 1 Credits™ and fulfills components of the American Board of Anesthesiology’s Maintenance of Certification in Anesthesiology Program (MOCA) 2.0® program, including up to 10 Part 4 points toward Improvement in medical practice.³³

ASRA Pain Medicine’s “Introduction to Perioperative Point of Care Ultrasound” course offers 29.25 American Medical Association Physician's Recognition Award (AMA PRA) Category 1 Credits™, via didactic and in-person training with expert feedback and qualifies for the didactic training of ASA’s certification. Both use online modules for the didactic portion of certification and rely on expert feedback to evaluate their learners' image acquisition and interpretation skills.³⁴

Due to the growing recognition of delayed gastric emptying in patients receiving GLP-1 RA, the ASA has introduced a five-part, web-based training pathway to build competence in gastric ultrasound, covering indications, image acquisition, interpretation, and clinical decision-making. This structured program addresses the urgent need for anesthesiologists and other acute care specialists to acquire gastric POCUS skills to enhance patient safety rapidly. The curriculum combines structured didactics, case-based interpretation training, mentored image acquisition of 30 logged gastric scans, and a final examination. Learners may work with either a local mentor or ASA faculty to verify image quality, culminating in a certificate of completion and digital badge that can support hospital credentialing or privileging processes. Participants may also earn up to 10 AMA PRA Category 1 Credits™ and 5 MOCA QI Part 4 points by completing quality improvement activities.³⁵

Summary

The evolving framework for competency-based training in perioperative POCUS emphasizes the limitations of scan numbers alone as a measure of proficiency and highlights the use of structured assessment tools, deliberate practice, and specialty-specific benchmarks. Evidence across applications, such as FAST, LUS, FoCUS, gastric, and airway ultrasound, demonstrates variable learning curves, with competency influenced by perceptual learning, supervised scan volume, simulation-based mastery, and performance metrics like checklists and global rating scales. Professional societies, including ASRA Pain Medicine, ASA, ACEP, and SCCM, recommend minimum scan thresholds, along with direct observation and interpretive accuracy assessments. Certification and structured courses mark the first step toward competency, but lifelong learning through continued scanning, image review, and staying current with advances remains essential. Moreover, emerging technologies, including artificial intelligence, hold the potential to transform how clinicians acquire, assess, and maintain POCUS proficiency in the future.

References

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