Towards a comprehensive and efficient assessment of regional anaesthesia competency

We commend Haddad et al. for an innovative pilot developing a 44-item assessment for ultrasound image interpretation in regional anaesthesia [1]. By adopting constructed-response items and contemporary test-development methods, including Rasch modelling and expert-led content validation, the authors address the cognitively demanding domain of sono-anatomy interpretation in a manner that more accurately reflects clinical reasoning than recognition-based formats. This contribution is timely, given that competence in ultrasound-guided regional anaesthesia is now embedded within national training frameworks [2]. This tool complements the established approaches that emphasise procedural performance, such as workplace-based direct observation, global rating scales and checklists, as well as knowledge testing using multiple-choice questions. Within this context, requiring free-text responses and calibrating items psychometrically is a meaningful advance and a useful addition to the repertoire of educators [1, 3]. Several features, however, warrant refinement if the instrument is to represent competence comprehensively. First, the scope of the instrument is intentionally limited. It samples only image interpretation from the widely recognised triad, omitting image acquisition and safe needle visualisation and handling, including procedural safety behaviours. The authors are explicit that the tool was designed for sono-anatomy and, therefore, does not assess acquisition or performance, reinforcing the case for pairing it with observed procedural evaluations. Second, the treatment of non-sonographic content warrants attention. In the pilot, items on dosing, equipment and safety were retained on the basis of expert judgement rather than being subjected to the same item-response analysis as the sono-anatomy items; the authors also note that some non-sono items were initially mapped to the 2010 Royal College of Anaesthetists curriculum and that future iterations will align with the current framework [2]. We believe this approach may limit psychometric coherence across domains, and we suggest applying Rasch modelling to all items in the main study to strengthen the validity argument and keep the instrument aligned with current standards [2]. The authors report that participants queried the omission of the transversus abdominis plane block, while the quadratus lumborum block was included. They clarify that this reflected the RA-UK Delphi categorisation (quadratus lumborum block as Plan BCD and transversus abdominis plane block as ‘other’), and that they are committed to including transversus abdominis plane blocks and newer blocks in subsequent versions [4, 5]. They also note a median completion time of 55 min, with fatigue commonly occurring around item 49, despite randomised ordering. We suggest that a shorter, information-efficient form or an adaptively delivered, calibrated item bank could preserve precision while reducing residual fatigue. The authors report strong internal consistency for the 44-item instrument (Cronbach's α 0.92) and outline a larger main study targeting approximately 100 participants to extend the psychometric evaluation. However, we recommend interpreting Cronbach's α with caution, as very high values may indicate redundant items following optimisation. Furthermore, we advocate conducting additional validity studies, such as test–retest reliability, cross-site generalisability and links to workplace outcomes, before using the instrument in high-stakes situations. Haddad et al. offer a methodologically careful and educationally relevant starting point for assessing ultrasound interpretation. Building on their work, we suggest a pragmatic path: shorten and de-duplicate the item set—or adopt adaptive delivery—to reduce fatigue; fully align the blueprint with the 2021 curriculum and maintain a transparent update cycle for block selection; and embed the interpretation test within a hybrid framework that also samples scanning technique, needle handling and safety behaviours through observed assessments (with objective metrics where appropriate). Such a curriculum-aligned, multimodal approach would better represent the clinical triumvirate of acquisition, interpretation and safe needling, to the benefit of trainees, trainers and patients.