From novice to proficient: a longitudinal study of POCUS skill development through a hybrid certification program in the United Arab Emirates

Abstract

Background

Point-of-care Ultrasound (POCUS) is rapidly becoming an indispensable tool in a wide range of medical specialties. To ensure that practicing physicians are fully equipped with the skills required, there is a need to expand comprehensive training opportunities, particularly in the Middle East and North Africa region. This study evaluates the effectiveness of a novel year-long hybrid POCUS certification program aimed at enhancing the confidence and competency of practicing physicians in the United Arab Emirates (UAE).

Methods

A prospective cohort study was conducted involving 12 practicing physicians enrolled in a one-year, part-time hybrid POCUS program. The program consisted of six modules that integrated online educational units, in-person workshops, and supervised clinical practice. Eligibility criteria for the program required participants to be licensed physicians with access to an ultrasound machine that had image storage capabilities within their healthcare setting. Participants’ confidence was assessed through self-reported surveys at four evaluation points. Competency was evaluated using the Ultrasound Competency Assessment Tool (UCAT) at three evaluation points, while ultrasound image quality was assessed throughout the program. Repeated measures of analysis of variance (ANOVA) were used to analyze changes in confidence and competency over time. Spearman’s correlation coefficients were calculated to examine the relationship between confidence and competency scores.

Results

Participants demonstrated significant improvements in both confidence and competency. Mean total confidence scores increased from 64.0 (SD = 9.9) pre-program to 81.3 (SD = 6.7) post-program (p < 0.001). The UCAT scores improved from 64.9 (SD = 13.5) in module two to 78.9 (SD = 3.6) in module six (p < 0.001). The UCAT scores for cardiac and lung applications showed the most consistent improvement, while the scores for first trimester ultrasound demonstrated the least improvement. Ultrasound image quality scores demonstrated a positive trend over time with a clear learning trajectory marked by three distinct phases. There was a significant association between ultrasound image quality scores and the number of completed ultrasound scan assignments (p < 0.001) for all applications except for first trimester ultrasound, indicating the need for curriculum enhancement in this area. A moderate positive correlation was observed between post-module four confidence scores and module six competence scores (r = 0.585, p = 0.059), however, this correlation was not statistically significant.

Conclusion

This comprehensive hybrid POCUS program effectively enhanced confidence and competency among practicing physicians. The structured approach, which integrates theoretical knowledge, hands-on practice, and ongoing longitudinal feedback, presents a promising model for POCUS education. These findings inform the development of similar programs, potentially improving POCUS adoption and patient care globally.

Clinical trial number

Not applicable.

Introduction

POCUS has emerged as a valuable diagnostic tool across various medical specialties, enabling rapid and accurate bedside assessments [1]. The effective use of POCUS requires physicians to possess a combination of theoretical knowledge, practical skills in operating ultrasound machines, and the ability to interpret images and integrate findings into clinical practice [2, 3]. Despite its growing importance, the primary challenge to implementing widespread POCUS adoption is the limited availability of comprehensive training opportunities for practicing physicians [5,6,7].

POCUS education has evolved significantly over the past decade, with various models emerging globally to address the growing demand for skilled practitioners [4, 33]. Traditional in-person programs, while effective, often face challenges of accessibility and scalability [33]. Hybrid learning models have gained prominence, particularly following the COVID-19 pandemic, with programs in North America and Europe demonstrating success in combining online learning with hands-on practice [10,11,12,13, 34]. These programs have shown promising results in knowledge retention and skill development, though they vary considerably in duration, structure, and assessment methods [35, 36].

The Middle East and North Africa (MENA) region presents unique challenges and opportunities in POCUS education. While the region is witnessing a growing integration of POCUS into clinical practice, comprehensive training opportunities remain limited [14,15,16]. Current POCUS training in the MENA region primarily consists of short courses lasting two to four days [14,15,16,17] or train-the-trainer models requiring international travel [18]. These approaches, while valuable, may not provide the sustained practice and feedback necessary for developing lasting competency in POCUS applications.

To address these gaps, the Fundamentals of POCUS Certification Program was developed, incorporating evidence-based educational principles from successful global programs while adapting to regional needs. The program’s design is grounded in three complementary educational theories: Adult Learning Theory (Andragogy) [19], Constructive Alignment Theory [20], and Experiential Learning Theory [21]. Adult Learning Theory informs the flexible, practice-oriented approach utilized, allowing participants to manage their learning while maintaining clinical responsibilities. Constructive Alignment Theory guides the assessment strategy, ensuring direct links between learning outcomes, activities, and evaluations. Experiential Learning Theory shapes the hands-on components, emphasizing the cycle of practice, reflection, and refinement.

This study aims to evaluate the effectiveness of this novel, comprehensive hybrid POCUS certificate program for physicians in practice in the UAE by assessing changes in participants’ confidence and competency levels and exploring the relationship between these two factors. Specifically, this study addresses the following research questions:

• 1. How does participants’ self-reported confidence in performing POCUS examinations change throughout the program?

• 2. To what extent does participants’ competency in performing POCUS examinations, as measured by the UCAT, improve throughout the program?

• 3. How do ultrasound image quality scores for various POCUS applications evolve as participants progress through their required educational scans?

• 4. What is the relationship between participants’ self-reported confidence and their measured competency in performing POCUS examinations?

• 5. Are there differences in the development of confidence and competency across different POCUS applications (e.g., cardiac, lung, abdominal aorta, trauma, first trimester)?

By addressing these questions, this study aims to provide insights into the effectiveness of the hybrid POCUS training model and contribute to the expanding repository of knowledge on POCUS education in the MENA region and beyond.

Methods

Study design and rationale

This study employed a prospective cohort repeated measures design to evaluate the effectiveness of the Fundamentals of POCUS Certification Program. While a randomized controlled trial would provide the highest level of evidence, ethical considerations and the pilot nature of this program influenced the design choice. Specifically, withholding comprehensive POCUS training from a control group of practicing physicians would have implications for patient care and professional development. Additionally, as the first structured, long-term POCUS certification program in the MENA region, this design allowed the collection of detailed longitudinal data about skill development patterns and learning trajectories. The study was approved by the Institutional Review Board of Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU IRB-2022-172).

Setting and participants

The study was conducted at Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), part of Dubai Health, an integrated academic healthcare system in Dubai, UAE. Participants were recruited through purposive sampling to ensure representation across different medical specialties. To be eligible for the program, participants had to be licensed physicians with access to an ultrasound machine with image storage capabilities within their healthcare setting. Prior experience with ultrasound was not required, allowing us to evaluate the program’s effectiveness across different baseline skill levels. Power calculations based on previous studies of POCUS education programs [34, 37] suggested a minimum sample size of 10 participants would be needed to detect a meaningful change in competency scores (effect size = 0.8, α = 0.05, power = 0.8). The final cohort of 12 participants exceeded this minimum threshold while remaining manageable for intensive supervision and feedback.

Program structure and design

The Fundamentals of POCUS Certification Program is a one-year, part-time hybrid program developed by faculty members at MBRU. It was led by a faculty member (R.B.), an Emergency Physician with advanced POCUS training and experience in teaching. Ten faculty members with advanced training and experience in POCUS from various medical specialties, including emergency medicine, general surgery, pediatric emergency medicine, and radiology, were involved in the program’s development and implementation.

To ensure a structured approach to program development, the ADDIE instructional design model [38] was utilized as the overarching framework, providing a systematic method for curriculum design. The Analysis phase involved assessing the gap in POCUS education in the UAE and identifying the need for a comprehensive certification program. The Design phase focused on structuring the program. International POCUS training guidelines informed the program’s design [2, 3, 9] and fundamental principles from three educational theories; Adult Learning Theory (Andragogy) [19], Constructive Alignment Theory [20], and Experiential Learning Theory [21], were incorporated. Adult Learning Theory is reflected in the program’s flexibility, which allows participants to manage their learning schedules through part-time and online modules. This approach ensured that the content was directly relevant to clinical practice and included experiential learning opportunities through simulations and hands-on practice. Constructive Alignment Theory was applied by defining specific learning outcomes for each POCUS application. This included a variety of learning activities such as interactive online units, hands-on workshops, and reflective case presentations, along with formative and summative assessments that were directly linked to the intended learning outcomes. Experiential Learning Theory was implemented through hands-on practice sessions with standardized patients, which incorporated formative assessments and feedback and encouraged skill application in clinical settings.

The Development phase involved developing the online modules, in-person workshops, and supervised clinical practice model. The Implementation phase focused on delivering training through a hybrid format, which enabled participants to apply their knowledge and skills in real-world settings. Finally, the Evaluation phase was guided by Kirkpatrick’s Training Evaluation Model [39], which incorporates a multi-level evaluation approach. Participants’ Reaction (Level 1) was gauged through feedback surveys administered at various stages of the program. These surveys aimed to capture participants’ initial impressions and satisfaction with the program’s content and delivery. Participants’ Learning (Level 2) was measured through a series of formative and summative assessments designed to evaluate the acquisition of knowledge, skills, and confidence levels throughout the program. To observe behavior changes in clinical practice (Level 3), participants’ utilization of ultrasound scans was tracked, and they were required to present examples of how the use of POCUS influenced their practice through case presentations. This level focused on measuring the translation of learning into practice. The ultimate impact of the program (Results, Level 4) will be assessed by examining patient outcomes one year after the program’s completion. This phase aims to determine the broader effects of training on clinical practice and patient care. This study assesses the program at Level 2 of Kirkpatrick’s model, focusing on participants’ learning outcomes.

The program is organized into six sequential modules, with each one building on the previous module’s content (Table 1). The first module, Theoretical Knowledge Acquisition, comprises seven asynchronous online educational units covering POCUS basics and applications delivered through a Learning Management System (LMS). These units include an introduction to POCUS, essential ultrasound physics and knobology, and five specific POCUS applications: basic cardiac, lung, trauma, early pregnancy, and abdominal aorta ultrasound. This module concludes with an online, open-book knowledge assessment quiz to verify that participants have acquired the essential basic knowledge before proceeding.

Table 1 POCUS program structure

The second module, Skills Development, is a two-day, in-person, hands-on workshop where participants practice operating ultrasound machines and performing the five fundamental ultrasound applications on standardized patients under direct faculty supervision. This module includes a formative competency evaluation for each ultrasound application, providing immediate feedback to participants on their skills development.

The third module, Practice in Clinical Workplace, allows participants to apply the skills they have learned in their clinical settings. During this module, participants complete a required number of educational ultrasound scan assignments for each POCUS application, bridging the gap between simulated practice and real-world application. A faculty member will review and evaluate the assignments submitted through the LMS, providing participants with feedback using a standardized ultrasound assignment evaluation tool. Details of the tool are provided in the data collection section.

The fourth module, Skills Refreshment, is another two-day in-person hands-on workshop designed for skills reinforcement. This module includes case presentations and reflections on clinical applications, allowing participants to share their experiences and learn from one another. Like the second module, it also includes a formative competency evaluation.

The fifth module, Complete e-portfolio, spans a 30-week period during which participants continue to practice and document POCUS examinations in their workplace settings. This extended period of supervised practice allows for the consolidation and refinement of skills across various clinical scenarios. By the end of this module, participants are expected to meet the program requirement of completing a minimum number of ultrasound scans for each POCUS application based on the recommended number of ultrasound examinations to ensure proficiency [3, 22, 23]. This includes 30 cardiac scans and 25 scans for each of the other POCUS applications, resulting in a total of 130 ultrasound scans throughout the program. The assignment evaluation and feedback mechanism is similar to the one described in module three.

The final Competency Assessment module consists of a comprehensive evaluation through a closed-book knowledge examination and an Objective Structured Clinical Examination (OSCE). The OSCE comprises five stations, each focusing on a single POCUS application, thoroughly assessing the participants’ practical skills and clinical reasoning.

Throughout the program, emphasis is placed on providing participants with longitudinal feedback. This is achieved through in-person formative assessments during modules two and four and asynchronous feedback on ultrasound assignments submitted during modules three and five.

The grading for the program is based on multiple components to ensure a comprehensive assessment of knowledge and skills. These components include an open-book quiz (10%), an e-portfolio (40%), a closed-book examination (25%), and an OSCE (25%). The distribution of these grading components reflects the relative importance of different competencies necessary for achieving proficiency in POCUS. The open-book quiz encourages engagement with foundational knowledge and its application in practical scenarios. The e-portfolio promotes sustained, reflective learning and documentation of skill progression over time. The closed-book examination and the OSCE, each accounting for 25% of the final grade, are intended to rigorously assess cognitive and practical competencies, respectively. Successful program completion requires a minimum overall score of 70%, ensuring that graduates have achieved a high standard of POCUS proficiency.

The comprehensive program structure (Fig. 1), grounded in educational theory and designed to provide progressive skill development with continuous feedback, aims to produce POCUS practitioners who are confident and competent in applying their skills in clinical practice.

Fig. 1

POCUS curriculum design alignment of learning outcomes, activities and assessment

Data collection

To address the research questions, the study employed a multi-faceted data collection strategy that captured participants’ confidence and competency development throughout the program. This strategy utilized three primary data collection tools: Self-assessment survey, UCAT and the Ultrasound assignment evaluation tool.

Self-assessment survey

This survey was designed to measure participants’ self-assessed confidence in conducting POCUS examinations, addressing the first research question (Appendix 1). It included questions regarding basic demographic information, previous experience with POCUS, and current confidence levels in general ultrasound skills, machine operations, and each POCUS application taught in the program. The self-assessment survey was adapted from Yamada et al.‘s validated instrument [24], which demonstrated high internal consistency (Cronbach’s α = 0.91) in evaluating POCUS skills acquisition. The tool for the specific POCUS applications was modified, while maintaining its validated five-point Likert scale structure [24]. The survey was distributed at four evaluation points throughout the program: before commencement (baseline), after the second module (skills development), after the fourth module (skills refreshment), and upon program completion. At each evaluation point, the survey was sent to participants via an online Microsoft Forms link, facilitating easy completion and data collection.

Ultrasound competency assessment tool (UCAT)

The UCAT was used to evaluate participants’ skills in performing POCUS examinations, addressing the second and fifth research questions (Appendix 2). The UCAT, developed by Bell et al., assesses performance in four domains: preparation, image acquisition, image optimization, and clinical integration. It also provides an overall entrustment rating [25, 26]. The study utilized the UCAT based on its demonstrated strong inter-rater reliability (ICC = 0.85) and internal consistency (Cronbach’s α = 0.92) for cardiac applications [25, 26]. While the tool has not been externally validated for all POCUS applications in the program, consistency was maintained through standardization sessions conducted with faculty evaluators prior to implementation.

The UCAT was administered at three evaluation points during the program: during the second module (after skills development), during the fourth module (after skills refreshment), and during the sixth module (final competency assessment in the OSCE). Faculty members used the UCAT to evaluate participants’ skills through an online Microsoft Forms during these in-person sessions.

Ultrasound assignment evaluation tool

This tool assessed the quality of ultrasound scans submitted by participants throughout the program, addressing the third research question (Appendix 3). The tool incorporates the validated Point-of-Care Ultrasound Image Quality (POCUS IQ) Scale for lung ultrasound [27] and a standardized dichotomous rating for image interpretation. Specific scoring criteria were developed through a modified Delphi process with the expert faculty panel to enhance reliability across different POCUS applications. Before implementation, all faculty members took part in a focused group meeting to review and discuss the tool, promoting consistent use among evaluators.

To submit their completed assignments, participants uploaded images and videos along with the assignment submission form to their e-portfolio on the LMS using Bongo software. Faculty members then reviewed these submissions on the LMS, evaluated the participants’ ultrasound assignments using the evaluation tool, and provided feedback on image acquisition skills and image interpretation. Each assignment received a composite score out of 20, consisting of 14 points for image quality from the POCUS IQ Scale and 6 points for the accuracy of image interpretation.

Data collection was ongoing throughout the one-year program, with specific evaluation points for each tool as described above. All data was collected and stored securely in compliance with institutional data protection policies.

This comprehensive data collection approach allowed us to track changes in self-reported confidence and objectively measured competency over time and assess the quality of ultrasound images produced by participants as they progressed through the program. This multidimensional assessment strategy provides a robust evaluation of the program’s effectiveness in developing POCUS skills among practicing physicians.

Statistical analyses

All statistical analyses were performed using SPSS version 29 IBM Corp. Released 2023. IBM SPSS Statistics for Windows, Version 29.0.2.0 Armonk, NY: IBM Corp). The significance level was set at p < 0.05 for all statistical tests.

Descriptive statistics

Participant characteristics and baseline data were summarized using descriptive statistics. Categorical variables were presented as frequencies and percentages. Numerical variables were presented as mean and standard deviation (SD). Shapiro-Wilk test was used to test the normality assumption and when the assumption was not met, an alternative analysis such as Spearman’s correlation was used.

Analysis of changes in confidence (research question 1)

To assess changes in participants’ self-reported confidence over the four evaluation points during the program, repeated measures ANOVA was used for the total confidence scores across the four-evaluation points (pre-program, post-module two, post-module four, and post-program). Mauchly’s test of sphericity was conducted to check the assumption of sphericity and Greenhouse-Geiser correction was applied when the Mauchly’s assumption was violated. Post-hoc pairwise comparisons with Bonferroni correction were conducted to identify specific evaluation points where significant changes occurred.

Analysis of changes in competency (research question 2)

Similar to the confidence analysis, repeated measures ANOVA was used to analyze changes in UCAT scores across the three assessment points (module two, module four, and module six). The same procedures for checking assumptions and conducting post-hoc tests were followed as described for the confidence analysis.

Analysis of ultrasound image quality scores (research question 3)

The mean scores for each POCUS application were plotted against the assignment number to examine the evolution of ultrasound image quality scores. A linear mixed-effects model was used to assess the relation between scores over time and the number of assignments, with the number of assignments as a fixed effect and individual participants as a random effect to account for repeated measures.

Relationship between confidence and competency (research question 4)

Spearman’s correlation coefficients were calculated to assess the relationship between self-reported confidence total scores and UCAT total scores at each evaluation point where both measures were available.

Differences across POCUS applications (research question 5)

To compare the development of confidence and competency across different POCUS applications, a two-way repeated measures ANOVA with time and POCUS application as within-subjects factors was employed. This analysis was conducted separately for confidence scores and UCAT scores. To compare the confidence scores, it was necessary to scale the values. However, there was no need to do the same when analyzing the UCAT scores. If significant interactions were found, simple main effects analyses were performed to examine application differences at each evaluation point.

Additional analyses

In addition, the magnitude of the changes in confidence and competency total scores between the beginning and the end of the program was quantified by calculating the mean change with 95% confidence interval (CI) for the mean changes.

Results

Participant demographics

Thirteen participants were initially enrolled in the program, with twelve completing it successfully. The cohort primarily consisted of female physicians (83.3%, n = 10), with emergency medicine being the predominant specialty (66.7%, n = 8). Half of the participants (50%, n = 6) reported prior POCUS exposure during residency training, though most (75%, n = 9) had no formal POCUS certification. The diverse range of prior experiences facilitated the evaluation of the program’s effectiveness across different baseline skill levels. Table 2 provides comprehensive participant characteristics.

Table 2 Participants characteristics (n = 12)

Longitudinal changes in self-reported confidence

Analysis of confidence assessments from six participants with complete data across all four evaluation points revealed substantial improvement throughout the program. The mean total confidence scores (maximum possible score: 85) showed progressive enhancement: pre-program (mean = 64.0, 95% CI [53.6, 74.4], SD = 9.9), post-second module (mean = 73.3, 95% CI [66.7, 80.0], SD = 6.3), post-fourth module (mean = 79.8, 95% CI [73.9, 85.7], SD = 5.6), and post-program (mean = 81.3, 95% CI [74.3, 88.37], SD = 6.7). The overall improvement from pre-program to post-program was significant (mean difference = 17.3, 95% CI [4.5, 30.1], p < 0.001). Figure 2 illustrates a line graph representing the self-assessment survey results collected at the four evaluation points during the program.

Fig. 2

Line graph of participants’ mean confidence scores at various evaluation time points

Analysis of application-specific confidence development (Table 3) demonstrated distinct patterns of confidence growth:

General Ultrasound Skills: These showed the most substantial early improvement (p = 0.005), particularly between pre-program and post-second module assessments, suggesting the effectiveness of initial hands-on training.

Cardiac Applications: These demonstrated significant growth (p = 0.015) with the greatest gains observed between pre-program and post-fourth module (mean difference = 15.2, 95% CI [2.1, 28.3], p = 0.046), indicating the value of extended practice time for complex applications.

First Trimester Ultrasound: While showing overall improvement (p = 0.021), these exhibited more variable progression, potentially reflecting limited clinical exposure opportunities for some participants.

Table 3 Participants’ confidence scores per application at various evaluation time points

Progression in POCUS competency

Analysis of UCAT scores from nine participants with complete data demonstrated consistent improvement across the three assessment points. The mean total scores (maximum: 85) progressed from module two (mean = 64.9, 95% CI [54.5, 75.3], SD = 13.5) through module four (mean = 70.9, 95% CI [65.1, 76.7], SD = 7.6) to module six (mean = 78.9, 95% CI [76.1, 81.6], SD = 3.6). The UCAT score of all POCUS applications scores during module six indicated a significant increase in competency compared to module two (p < 0.001). The improvement in the total competency scores throughout the course was quantified (improvement mean = 13.5, 95% CI = (6.3, 20.7)). Figure 3 illustrates a line graph representing the UCAT results collected at the three evaluation points during the program.

Fig. 3

Line graph of participants’ mean overall ucat scores at various evaluation time points

Analysis of application-specific competency development (Table 4) revealed varying patterns

Cardiac and Lung Applications: These demonstrated the most consistent improvement in competency (p = 0.01 and p = 0.001, respectively).

First Trimester Ultrasound: Although participants had high mean UCAT scores compared to other ultrasound applications, the repeated measures of the UCAT scores for the first trimester ultrasound application showed the least improvement (p = 0.078). This aligns with the findings on confidence and highlights a potential area for curriculum enhancement.

Table 4 Participants’ UCAT scores per application at various evaluation time points

Evolution of ultrasound image quality

Analysis of ultrasound image quality scores (Fig. 4) revealed a clear learning trajectory with three distinct phases

Initial Rapid Improvement (Assignments 1–15): Characterized by steep increases in scores across all applications, particularly in cardiac and lung imaging.

Plateau Phase (Assignments 15–18): Scores stabilized across applications, suggesting achievement of basic proficiency.

Refinement Phase (Assignments 19+): Showed modest but continued improvement with reduced variability, indicating development of consistent technique.

Statistical analysis confirmed significant association between assignment completion and score improvement (p < 0.001) for all applications except first trimester ultrasound (p = 0.109).

Fig. 4

Line graph of participants’ mean assignment scores per POCUS application

Confidence– competency relationship

The relationship between self-reported confidence and measured competency showed interesting temporal patterns (Fig. 5). While the overall correlation was modest, a moderate positive correlation was observed between post-module four confidence scores and the final competency assessment (r = 0.585, 95% CI [0.021, 0.872], p = 0.059). This finding suggests that confidence levels after substantial hands-on experience may be more predictive of ultimate competency than earlier self-assessments.

Fig. 5

Results of the correlation analysis between participants’ confidence scores and ucat scores at various evaluation time points

Differences across POCUS applications

The two-way repeated measures ANOVA analysis results indicated that there was a significant improvement in the confidence scores throughout the course time (p = 0.024), but there was no significant difference between the applications (p = 0.484), and no interaction between the time and the applications (p = 0.533) (Fig. 6).

Fig. 6

Line graphs of participants’ mean confidence score per application at various evaluation time points

The same results were found for the competency scores (Fig. 7); there was a significant improvement in the competency scores throughout the course time (p < 0.001), but there was no significant difference between the applications (p = 0.091), and no interaction between the time and the applications (p = 0.854).

Fig. 7

Line graphs of participants’ mean ucat score per application at various evaluation time points

These findings confirmed the results of the improved confidence and competence observed in the program.

Discussion

This longitudinal study evaluated the effectiveness of a comprehensive hybrid POCUS certification program designed specifically for practicing physicians in the UAE. The findings demonstrate significant improvements in self-reported confidence and objectively measured competency across most ultrasound applications while highlighting important areas for program refinement.

Program effectiveness and learning trajectories

The progressive increase in confidence scores from baseline to program completion highlights the effectiveness of the structured, theory-based POCUS education approach on which this program is founded. The most substantial gains in confidence occurred between the pre-program assessment and post-module four, suggesting that the combination of didactic content, hands-on workshops, and supervised clinical practice effectively supports skill development. This aligns with findings from similar hybrid programs in other regions, where structured combinations of online and hands-on learning have shown positive results [10, 11, 34].

The competency assessments revealed distinct learning patterns across different POCUS applications. Cardiac and lung ultrasound demonstrated the most consistent improvement and highest final competency scores. This success likely stems from several factors: the relatively standardized scanning protocols, frequent clinical opportunities for practice, and clear anatomical landmarks. In contrast, the more modest improvement in first-trimester ultrasound competency highlights an important area for program enhancement. This challenge may arise from limited clinical exposure opportunities in specialized hospital settings and the more complex nature of early pregnancy ultrasound interpretation.

Learning curve and skill development

The analysis of ultrasound image quality scores revealed a noteworthy pattern in skill acquisition. The plateau observed between the 15th and 18th assignments across most applications suggests this may represent a critical threshold for achieving basic proficiency. This finding aligns with previous research by Millington et al. [23], who identified similar learning plateaus in critical care echocardiography training. Understanding this pattern has important implications for curriculum design and could help establish evidence-based benchmarks for minimum scanning requirements.

Confidence-competency relationship

The moderate positive correlation between post-module four confidence scores and final competency assessments provides interesting insights into the relationship between self-assessment and actual skill development. The timing of this correlation suggests that learners may achieve more accurateself-assessment following substantial hands-on experience. This finding contributes to the ongoing discourse in medical education regarding the nuanced relationship between confidence and competence [29, 30]. Educators should take this into account when designing assessment strategies and providing feedback throughout the learning process.

Program design and educational theory

The success of the program supports the value of incorporating established educational theories into POCUS training design. The Adult Learning Theory principles manifested in the program’s flexible structure and clinical relevance appeared to support sustained engagement. The Constructive Alignment Theory guided the assessment strategy, ensuring direct links between learning objectives and evaluation methods. The Experiential Learning cycle was evident in the progression of skills through repeated practice and reflection.

Regional impact and future directions

As the first comprehensive POCUS certification program in the MENA region, these findings hold significant implications for bridging the regional training gap. The hybrid format successfully addressed traditional barriers to extended POCUS training, such as geographic distance and clinical commitments. Nevertheless, the variability in improvement across different applications suggests the need for tailored approaches that align with local practice patterns and clinical exposure opportunities.

Study limitations and recommendations

The study has several important limitations to consider when interpreting the findings and planning future research in POCUS education. These limitations span methodological design, assessment tools, sample characteristics, and follow-up duration.

While practical for this pilot program, the single cohort repeated measures design introduces several methodological constraints. The absence of a control group makes it challenging to definitively attribute the observed improvements to the educational intervention alone. While ethical considerations and resource limitations influenced this design choice, future studies would benefit from incorporating matched control groups, comparing different educational approaches or implementing a waiting-list control design.

Although exceeding the minimal power calculations, the sample size of twelve participants limits the statistical robustness and generalizability of the findings. The small sample and incomplete datasets mainly affected the ability to conduct meaningful subgroup analyses and reduced the precision of the effect size estimates. The cohort’s predominantly female (83.3%) and emergency medicine-focused (66.7%) composition further constrain the findings’ generalizability to broader physician populations. Future iterations of the program should aim for larger, more diverse cohorts to represent better the variety of medical specialties utilizing POCUS.

The assessment tools used in the study present another limitation. While the UCAT has demonstrated strong reliability for cardiac applications, its validation for other POCUS applications remains incomplete. Similarly, the POCUS IQ Scale, although validated for lung ultrasound, lacks comprehensive validation for other applications covered in the program. This limitation in assessment tool validation introduces potential measurement bias, particularly when evaluating competency across different POCUS applications. Although faculty standardization sessions were conducted to mitigate this limitation, future research should prioritize validating these assessment tools across all POCUS applications.

The reliance on self-reported confidence data introduces potential reporting bias. Participants’ self-assessments may be influenced by various factors including social desirability bias and varying levels of self-awareness. The moderate correlation that was found between confidence and competency scores highlights the complex nature of self-assessment in medical education and suggests the need for more objective measures of skill development.

The study’s timeframe, while longer than many POCUS training programs, lacks long-term follow-up data. This limitation prevents us from understanding the durability of acquired skills and knowledge, as well as the program’s impact on clinical practice patterns. Future research should incorporate follow-up assessments at 6-, 12-, and 24-months post-program completion to evaluate skill retention, clinical implementation and impact on patient outcomes.

The program’s implementation at a single institution in the UAE may limit its applicability to other healthcare settings and cultural contexts. While the program was designed to address regional needs, the specific institutional resources and support available may not represent other healthcare systems in the MENA region or globally.

The study did not systematically collect data on participants’ clinical exposure opportunities during the program. The observed variability in improvement across different POCUS applications, particularly in first-trimester ultrasound, may be attributed to differences in clinical practice opportunities rather than the effectiveness of the program itself. Future research should incorporate structured documentation of clinical exposure and hands-on practice opportunities.

Conclusions

This longitudinal study provides compelling evidence for the effectiveness of a comprehensive, hybrid POCUS training program in enhancing the confidence and competence of practicing physicians. The findings demonstrate significant improvements across multiple POCUS applications, with participants showing substantial growth in self-reported confidence and objectively measured competency throughout the one-year program.

The program’s structured progression through theoretical knowledge acquisition, hands-on skill development, and clinical application, supported by longitudinal feedback, emerges as a promising framework for POCUS education. The observed learning trajectories, particularly the plateau effect identified between the 15th and 18th assignments, provide valuable insights for establishing evidence-based benchmarks in POCUS training. These findings suggest that approximately 15–18 supervised scans per application may represent a critical threshold for achieving basic proficiency.

The results highlight the effectiveness of a multi-modal learning approach that combines asynchronous online modules, in-person workshops, and supervised clinical practice. This hybrid model effectively addresses common barriers to POCUS training, particularly in regions with limited access to comprehensive, longitudinal training. The varying improvement patterns across different POCUS applications, with cardiac and lung ultrasound showing more consistent progress than first-trimester ultrasound, provide important considerations for future curriculum refinement.

While acknowledging the limitations of the single-cohort study design and sample size, these findings contribute meaningfully to the growing body of knowledge in POCUS education. The program’s success in the UAE context suggests potential applicability to other healthcare systems, particularly in regions seeking to establish structured POCUS training programs. Future research should focus on validating these findings through larger, multi-center studies and investigating the long-term retention of acquired skills.

The implications of this study extend beyond immediate educational outcomes. By demonstrating the feasibility and effectiveness of a comprehensive hybrid POCUS training program, this work offers a scalable model that can be adapted and implemented across diverse healthcare settings. As POCUS becomes increasingly integrated into clinical practice, the insights gained from this study can inform the development of evidence-based training programs, ultimately enhancing patient care through the effective application of POCUS.