Confidence-Competence Calibration in Early Procedural Skill Acquisition: Evidence from Musculoskeletal Ultrasound Training.

Abstract

We examined relationships among learner-reported outcomes and assessed alignment between confidence and objective examination performance during early MSKUS skill acquisition. Learners in the Ultrasound School of North American Rheumatologists Fundamentals program were evaluated in the 2024 and 2025 cohorts. The 8-month program included virtual instruction, standardized scanning protocols, a 3-day hands-on workshop, longitudinal image submission with feedback, and written and practical examinations. Subjective measures included confidence in scanning and interpretation, perceived knowledge, and perceived ability to apply ultrasound in the work setting. Spearman correlations assessed associations among subjective measures and between confidence and continuous examination scores; threshold-sensitivity categorical analyses were secondary. Subjective-objective analyses were limited to 2025 because individual linkage was unavailable for 2024. Among 118 learners, perceived knowledge and ability-to-apply data were available for 93. Linked subjective and written examination data were available for 70; practical scores for 69. Subjective domains were positively associated (knowledge with confidence ⍴ = 0.46, p < 0.001; confidence with ability to apply ⍴ = 0.32, p = 0.007). Confidence was not associated with written performance (⍴ = -0.04, p = 0.74) or practical performance (⍴ = -0.16, p = 0.20) in continuous analyses, and no categorical threshold reached significance (all p ≥ 0.054). Miscalibration was bidirectional: 39% overconfident, 35% underconfident and 26% calibrated. Among early MSKUS learners, confidence aligned with other learner-reported outcomes but did not discriminate objective competence. This calibration gap suggests that learner- reported readiness should not determine preparedness for independent scanning and supports objective competency assessment.