Ultrasound Obstet Gynecol 2018; 52: 424–426 Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.19071 Editorial Use of ultrasound simulators for assessment of trainee competence: trendy toys or valuable instruments? M. G. TOLSGAARD 1,2,3 * and G. E. CHALOUHI 3,4,5 1 Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; 2 Copenhagen Academy for Medical Education and Simulation (CAMES) Rigshospitalet, Copenhagen, Denmark; 3 Basic Training Task Force, Education Committee, International Society of Ultrasound in Obstetrics and Gynecology (ISUOG); 4 SimECHOle, ´ Ecole de Simulation pour l’enseignement et le perfectionnement en ´ Echographie Gyn´ ecologique et Obst´ etricale, Paris, France; 5 Faculty of Medicine, Saint Joseph University, Beirut, Lebanon *Correspondence. (e-mail: martintolsgaard@gmail.com) Introduction Over the past decade, ultrasound simulators have been used increasingly as an adjunct to clinical training in the field of obstetrics and gynecology. Studies have shown that simulation-based ultrasound training leads to sustained improvement in clinical performance 1 , including improved diagnostic accuracy 2 , reduced need for supervised practice and decreased patient discomfort 3 . In addition to being a valuable tool for training, ultrasound simulators can also be used for the assessment of trainee competence. There are several potential advantages associated with the use of simulation-based assessment of competence, but also some limitations and challenges. To that end, one of the main focus areas of the Basic Training Task Force, which was established by the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) in 2015, is to clarify the role of ultrasound simulators in the assessment of trainee competence. The purpose of this editorial is to provide a summary of the recommendations proposed by the ISUOG Basic Training Task Force on how to use simulation-based assessments of ultrasound competence, and to address the associated advantages and challenges. Benefits of simulation-based assessment of trainee competence There are many good reasons to consider the use of ultrasound simulators for the assessment of trainee competence as an adjunct or alternative to in-training assessment in the clinical setting. Firstly, in-training assessment of competence in the clinical setting requires the investment of a considerable amount of time by the faculty, which is not always possible owing to competing clinical obligations. Moreover, the use of real patients for intimate examinations such as the assessment of transvaginal ultrasound skills is neither feasible nor ethical when conducting large-scale licensing exams 4 . In these cases, simulation-based assessment of competence may be used instead, without compromising significantly the validity of assessments 5 . For example, at the 2016 annual obstetrics and gynecology ultrasound licensing examination that took place in Paris, more than 100 trainees were evaluated on a transvaginal ultrasound simulator in order to determine their diagnostic accuracy across five cases with or without pathology. Secondly, in-training assessment of competence in the clinical setting is challenged by a lack of standardized assessment methods and criteria, which often vary between different examiners, institutions and countries 6 . On the other hand, simulation-based assessment has the advantage of providing standardized and valid measures of competence that can be compared between institutions and countries 7 . Thirdly, volume-based measures, i.e. the number of examinations that have been performed by a trainee, may be poor indicators of competence compared with performance-based measures, such as those achieved through direct observation of scans in the clinical setting or through assessments in the simulation setting. Instead of being directly evaluated on their practical skills, trainees are often allowed to practice independently after having completed a certain number of supervised scans. For example, ISUOG’s basic training recommendations advise that trainees should have completed at least 100 supervised scans before independent practice is commenced 8 . However, there is little empirical evidence to support the idea that performing a certain number of scans ensures trainee competence. On the contrary, studies have found that the time trainees need to attain expert levels of competence in performing ultrasound varies significantly 7,9,10 . Given that the ultimate goal is that trainees practice safely and independently, setting a fixed number of scans as an indicator of competence may result in allowing some trainees who have not yet achieved the required competence to practice independently, while delaying independent practice for those who have attained competence through fewer than the designated number of scans 1 . Recently, we examined the relationship between diagnostic accuracy and number of completed ultrasound examinations in a large group of sonologists. Those who had completed more than 100 scans had an average diagnostic accuracy of 70%, which improved only slightly (to 72%) for sonologists who had completed more than 300 scans (Tolsgaard & Chalouhi, unpubl. data). Copyright  2018 ISUOG. Published by John Wiley & Sons Ltd. EDITORIAL