Table 1 Blended learning curriculum paradigm

Step I: Formal Coursework

Month 1

Coursework consisted of asynchronous learning by way of the SonoSim platform education tool, with limited in-person didactic style modules and simulations paired with hands-on teaching by educational faculty. Pre-reading assignments included selections from literature, textbook chapters, and online resources; in addition, for the Blended Learning Curriculum, asynchronous learning modules are outlined (see Additional file 1).

Step II: Portfolio Development

Month 2–12

Each trainee developed and maintained image sets in digital portfolios according to a mandatory list and the cases they participate in. Portfolio development was divided into four levels of independent image acquisition in the medical ICU (see Additional file 2).

Step III: Deliberate Practice Session

Month 6

Trainees participated in a two-hour, individualized learner and instructor session including review of self-perceived strengths and weaknesses, review of image portfolio and a skills practical, the contents of which are provided (see Additional file 3).

Step IV: Portfolio Maintenance

Month 2–12 with case presentations scheduled quarterly

Fellows presented a new or ongoing case and discussed the ultrasound images and techniques used to manage the patient. This was followed by a short didactic on a topic relevant to the case.

Step V: Clinically Targeted Sessions

Month 2–12 with educational events scheduled quarterly

Fellows participated in group scanning sessions, targeted towards combining US imaging findings clinical context. Sessions included US rounds in the medical ICU, US consultation services on medicine, medical ICU and pulmonary teams, US electives, US during and after cardiac arrest events, case-based sessions, patients with dyspnea, patients with undifferentiated shock, and conducting an IVC evaluation for fluid responsiveness.

Step VI: Training the Trainer

Month 6–12 with educational events occurring once or twice

Fellows participated in train the trainer sessions, patient care sessions in which the trainee guides the trainer. A trainee taught at the student, resident, and junior fellow level under supervision of the trainer, and a provided guide for the trainee is provided (see Additional file 4).

Step VII: Final Competency Testing and Review

End of final year of PCCM Fellowship

Prior to program graduation, core bedside US skills and knowledge were tested in objective structured clinical examination (OSCE) format. Case introduction is provided in a case file (see Additional file 5), the corresponding videos are provided separately (see Additional file 6), and the answer key is provided (see Additional file 7).