Teaching crucial skills: An electrocardiogram teaching module for medical students

Effectiveness of electrocardiogram interpretation education program using mixed learning methods and webpage

AIM

This study was conducted to develop an electrocardiogram education program that incorporates an HTML webpage and blended learning methods to enhance electrocardiogram interpretation skills. Through continual and efficient education, the program aims to assist nurses in providing appropriate care and treatment to patients.

DESIGN

Pre-post design study.

METHODS

We developed an electrocardiogram interpretation HTML webpage based on an electrocardiogram interpretation algorithm and implemented an 18-week (2023.5.15 ~ 2023.9.22) electrocardiogram education program, which included daily 5-minute training sessions. Twenty-seven ward nurses were provided with the URL ( https://ecgweb.github.io/ECGwebEN ) to the electrocardiogram interpretation HTML webpage and shared one electrocardiogram case daily for self-interpretation. Electrocardiogram interpretation performance and confidence were evaluated through questionnaires at three phases: before the program, after 6 weeks of basic electrocardiogram and arrhythmia education, and after 12 weeks of application of the electrocardiogram interpretation HTML webpage and case-based lecture education. The statistical tests used were repeated-measures ANOVA or the Wilcoxon signed-rank test.

RESULTS

The average score for electrocardiogram interpretation performance before the electrocardiogram education program was 11.89(SD = 3.50), after 6 weeks of basic electrocardiogram and arrhythmia education it was 14.15(SD = 3.68), and after 12 weeks of application of the electrocardiogram interpretation HTML webpage and case-based lecture education, it was 15.56(SD = 3.04). This shows that electrocardiogram interpretation performance significantly improved over time (p < .001). Additionally, post-hoc analysis revealed significant differences in electrocardiogram interpretation performance at each stage, i.e., before, during, and after the application of an electrocardiogram education program. Furthermore, the electrocardiogram interpretation confidence questionnaire score (pre-Median 18, IQR = 5; post-Median 23, IQR = 3) was improved significantly after the completion of the 18-week education program (p < .001).

CONCLUSIONS

Based on the results of this study, we believe that an electrocardiogram education program using HTML webpage, and a blended teaching method would be very beneficial for maintaining and improving electrocardiogram interpretation skills of clinical nurses. Such a program can help nurses interpret electrocardiograms more effectively and assist them in making important decisions in patient care.

Comparing the effectiveness of asynchronous e-modules and didactic lectures to teach electrocardiogram interpretation to first year US medical students

BACKGROUND

Medical students are expected to be competent in interpreting electrocardiograms (ECGs) by the time they graduate, but many are unable to master this skill. Studies suggest that e-modules are an effective way to teach ECG interpretation, however they are typically evaluated for use during clinical clerkships. We sought to determine if an e-module could replace a didactic lecture to teach ECG interpretation during a preclinical cardiology course.

METHODS

We developed an asynchronous, interactive e-module that consisted of narrated videos, pop-up questions and quizzes with feedback. Participants were first year medical students who were either taught ECG interpretation during a 2-hour didactic lecture (control group) or were given unlimited access to the e-module (e-module group). First-year internal medicine residents (PGY1 group) were included to benchmark where ECG interpretation skills should be at graduation. At three time-points (pre-course, post-course, and 1-year follow-up), participants were evaluated for ECG knowledge and confidence. A mixed-ANOVA was used to compare groups over time. Students were also asked to describe what additional resources they used to learn ECG interpretation throughout the study.

RESULTS

Data was available for 73 (54%) students in the control group, 112 (81%) in the e-module group and 47 (71%) in the PGY1 group. Pre-course scores did not differ between the control and e-module groups (39% vs. 38%, respectively). However, the e-module group performed significantly better than the control group on the post-course test (78% vs. 66%). In a subsample with 1-year follow-up data, the e-module group's performance decreased, and the control group remained the same. The PGY1 groups' knowledge scores were stable over time. Confidence in both medical student groups increased by the end of the course, however only pre-course knowledge and confidence were significantly correlated. Most students relied on textbooks and course materials for learning ECG, however online resources were also utilized.

CONCLUSIONS

An asynchronous, interactive e-module was more effective than a didactic lecture for teaching ECG interpretation, however continued practice is needed regardless of how students learn to interpret ECGs. Various ECG resources are available to students to support their self-regulated learning.

Physician Training for Electrocardiogram Interpretation: A Systematic Review and Meta-Analysis

PURPOSE

Using electrocardiogram (ECG) interpretation as an example of a widely taught diagnostic skill, the authors conducted a systematic review and meta-analysis to demonstrate how research evidence on instruction in diagnosis can be synthesized to facilitate improvement of educational activities (instructional modalities, instructional methods, and interpretation approaches), guide the content and specificity of such activities, and provide direction for research.

METHOD

The authors searched PubMed/MEDLINE, Embase, Cochrane CENTRAL, PsycInfo, CINAHL, ERIC, and Web of Science databases through February 21, 2020, for empirical investigations of ECG interpretation training enrolling medical students, residents, or practicing physicians. They appraised study quality with the Medical Education Research Study Quality Instrument and pooled standardized mean differences (SMDs) using random effects meta-analysis.

RESULTS

Of 1,002 articles identified, 59 were included (enrolling 17,251 participants). Among 10 studies comparing instructional modalities, 8 compared computer-assisted and face-to-face instruction, with pooled SMD 0.23 (95% CI, 0.09, 0.36) indicating a small, statistically significant difference favoring computer-assisted instruction. Among 19 studies comparing instructional methods, 5 evaluated individual versus group training (pooled SMD -0.35 favoring group study [95% CI, -0.06, -0.63]), 4 evaluated peer-led versus faculty-led instruction (pooled SMD 0.38 favoring peer instruction [95% CI, 0.01, 0.74]), and 4 evaluated contrasting ECG features (e.g., QRS width) from 2 or more diagnostic categories versus routine examination of features within a single ECG or diagnosis (pooled SMD 0.23 not significantly favoring contrasting features [95% CI, -0.30, 0.76]). Eight studies compared ECG interpretation approaches, with pooled SMD 0.92 (95% CI, 0.48, 1.37) indicating a large, statistically significant effect favoring more systematic interpretation approaches.

CONCLUSIONS

Some instructional interventions appear to improve learning in ECG interpretation; however, many evidence-based instructional strategies are insufficiently investigated. The findings may have implications for future research and design of training to improve skills in ECG interpretation and other types of visual diagnosis.

Assessments of Physicians' Electrocardiogram Interpretation Skill: A Systematic Review

PURPOSE

To identify features of instruments, test procedures, study design, and validity evidence in published studies of electrocardiogram (ECG) skill assessments.

METHOD

The authors conducted a systematic review, searching MEDLINE, Embase, Cochrane CENTRAL, PsycINFO, CINAHL, ERIC, and Web of Science databases in February 2020 for studies that assessed the ECG interpretation skill of physicians or medical students. Two authors independently screened articles for inclusion and extracted information on test features, study design, risk of bias, and validity evidence.

RESULTS

The authors found 85 eligible studies. Participants included medical students (42 studies), postgraduate physicians (48 studies), and practicing physicians (13 studies). ECG selection criteria were infrequently reported: 25 studies (29%) selected single-diagnosis or straightforward ECGs; 5 (6%) selected complex cases. ECGs were selected by generalists (15 studies [18%]), cardiologists (10 studies [12%]), or unspecified experts (4 studies [5%]). The median number of ECGs per test was 10. The scoring rubric was defined by 2 or more experts in 32 studies (38%), by 1 expert in 5 (6%), and using clinical data in 5 (6%). Scoring was performed by a human rater in 34 studies (40%) and by computer in 7 (8%). Study methods were appraised as low risk of selection bias in 16 studies (19%), participant flow bias in 59 (69%), instrument conduct and scoring bias in 20 (24%), and applicability problems in 56 (66%). Evidence of test score validity was reported infrequently, namely evidence of content (39 studies [46%]), internal structure (11 [13%]), relations with other variables (10 [12%]), response process (2 [2%]), and consequences (3 [4%]).

CONCLUSIONS

ECG interpretation skill assessments consist of idiosyncratic instruments that are too short, composed of items of obscure provenance, with incompletely specified answers, graded by individuals with underreported credentials, yielding scores with limited interpretability. The authors suggest several best practices.

Effects of peer learning on nursing students' learning outcomes in electrocardiogram education

BACKGROUND

Nurses should have the ability to interpret electrocardiograms (ECGs) quickly and accurately, but their ECG interpretation skills may be suboptimal. The best evidence for effective teaching methods is lacking.

OBJECTIVES

This study aimed to compare the effects of peer and self-directed individual learning methods on nursing students' learning flow, interpretation skills, and self-confidence in web-based ECG education.

DESIGN

This study employed a nonequivalent control group with a pretest-posttest design.

SETTINGS

This study was conducted at two colleges of nursing in the Republic of Korea.

PARTICIPANTS

Nursing students were conveniently assigned to either a peer learning group (n = 45) or a self-directed individual learning group (n = 51).

METHODS

A self-administered questionnaire was used to measure the nursing students' learning flow and self-confidence in ECG rhythm interpretation. ECG interpretation skills were measured using a web-based interpretation skills test. Data were analyzed using a paired t-test and a two-sample t-test.

RESULTS

Nursing students in both groups showed improved learning flow, interpretation skills, and self-confidence after ECG education compared with before learning. However, there were no significant pretest-posttest differences in learning flow, interpretation skills, or self-confidence between the two groups.

CONCLUSIONS

Peer learning was as effective as self-directed individual learning in improving nursing students' learning flow, interpretations skills, and self-confidence in web-based education. Nurse educators should educate nursing students to have optimal ECG interpretation abilities, and web-based peer or individual learning are effective education methods.

Utilizing Supplemental Online Modules for Physician Assistant Student Electrocardiogram Interpretation Training

PURPOSE

The literature suggests that graduating medical and physician assistant (PA) students lack competency in electrocardiogram (ECG) interpretation. This project aimed to determine whether use of perceptual adaptive learning modules (PALMs) would improve PA students' ECG interpretation, alter self-perceptions of their ECG education, or both.

METHODS

PALMs were incorporated into the PA curriculum after lecture-based ECG learning. Students' pretest, posttest, and delayed-posttest scores were then compared. Students' ability to correctly interpret ECGs (accuracy) and the percentage of ECGs accurately interpreted within 15 seconds or less (fluency) also were evaluated. Finally, students' perceptions of PALMs and overall ECG training were assessed.

RESULTS

PALM training improved ECG interpretation accuracy and fluency (p < .0001), as well as delayed-posttest accuracy and fluency (p < .0001). The majority of student respondents felt supplemental training enhanced their learning.

CONCLUSION

These perception results combined with data on ECG interpretation improvement supports continued use of supplemental PALMs in ECG interpretation training.

Effectiveness of blended learning versus lectures alone on ECG analysis and interpretation by medical students

BACKGROUND

Most medical students lack confidence and are unable to accurately interpret ECGs. Thus, better methods of ECG instruction are being sought. Current literature indicates that the use of e-learning for ECG analysis and interpretation skills (ECG competence) is not superior to lecture-based teaching. We aimed to assess whether blended learning (lectures supplemented with the use of a web application) resulted in better acquisition and retention of ECG competence in medical students, compared to conventional teaching (lectures alone).

METHODS

Two cohorts of fourth-year medical students were studied prospectively. The conventional teaching cohort (n = 67) attended 4 hours of interactive lectures, covering the basic principles of Electrocardiography, waveform abnormalities and arrhythmias. In addition to attending the same lectures, the blended learning cohort (n = 64) used a web application that facilitated deliberate practice of systematic ECG analysis and interpretation, with immediate feedback. All participants completed three tests: pre-intervention (assessing baseline ECG competence at start of clinical clerkship), immediate post-intervention (assessing acquisition of ECG competence at end of six-week clinical clerkship) and delayed post-intervention (assessing retention of ECG competence 6 months after clinical clerkship, without any further ECG training). Diagnostic accuracy and uncertainty were assessed in each test.

RESULTS

The pre-intervention test scores were similar for blended learning and conventional teaching cohorts (mean 31.02 ± 13.19% versus 31.23 ± 11.52% respectively, p = 0.917). While all students demonstrated meaningful improvement in ECG competence after teaching, blended learning was associated with significantly better scores, compared to conventional teaching, in immediate (75.27 ± 16.22% vs 50.27 ± 17.10%, p <  0.001; Cohen's d = 1.58), and delayed post-intervention tests (57.70 ± 18.54% vs 37.63 ± 16.35%, p <  0.001; Cohen's d = 1.25). Although diagnostic uncertainty decreased after ECG training in both cohorts, blended learning was associated with better confidence in ECG analysis and interpretation.

CONCLUSION

Blended learning achieved significantly better levels of ECG competence and confidence amongst medical students than conventional ECG teaching did. Although medical students underwent significant attrition of ECG competence without ongoing training, blended learning also resulted in better retention of ECG competence than conventional teaching. Web applications encouraging a stepwise approach to ECG analysis and enabling deliberate practice with feedback may, therefore, be a useful adjunct to lectures for teaching Electrocardiography.

Accuracy of Physicians' Electrocardiogram Interpretations: A Systematic Review and Meta-analysis

IMPORTANCE

The electrocardiogram (ECG) is the most common cardiovascular diagnostic test. Physicians' skill in ECG interpretation is incompletely understood.

OBJECTIVES

To identify and summarize published research on the accuracy of physicians' ECG interpretations.

DATA SOURCES

A search of PubMed/MEDLINE, Embase, Cochrane CENTRAL (Central Register of Controlled Trials), PsycINFO, CINAHL (Cumulative Index to Nursing and Allied Health), ERIC (Education Resources Information Center), and Web of Science was conducted for articles published from database inception to February 21, 2020.

STUDY SELECTION

Of 1138 articles initially identified, 78 studies that assessed the accuracy of physicians' or medical students' ECG interpretations in a test setting were selected.

DATA EXTRACTION AND SYNTHESIS

Data on study purpose, participants, assessment features, and outcomes were abstracted, and methodological quality was appraised with the Medical Education Research Study Quality Instrument. Results were pooled using random-effects meta-analysis.

MAIN OUTCOMES AND MEASURES

Accuracy of ECG interpretation.

RESULTS

Of 1138 studies initially identified, 78 assessed the accuracy of ECG interpretation. Across all training levels, the median accuracy was 54% (interquartile range [IQR], 40%-66%; n = 62 studies) on pretraining assessments and 67% (IQR, 55%-77%; n = 47 studies) on posttraining assessments. Accuracy varied widely across studies. The pooled accuracy for pretraining assessments was 42.0% (95% CI, 34.3%-49.6%; n = 24 studies; I2 = 99%) for medical students, 55.8% (95% CI, 48.1%-63.6%; n = 37 studies; I2 = 96%) for residents, 68.5% (95% CI, 57.6%-79.5%; n = 10 studies; I2 = 86%) for practicing physicians, and 74.9% (95% CI, 63.2%-86.7%; n = 8 studies; I2 = 22%) for cardiologists.

CONCLUSIONS AND RELEVANCE

Physicians at all training levels had deficiencies in ECG interpretation, even after educational interventions. Improved education across the practice continuum appears warranted. Wide variation in outcomes could reflect real differences in training or skill or differences in assessment design.

Generalist practitioners' self-rating and competence in electrocardiogram interpretation in South Africa

Background

Electrocardiogram (ECG) is the only practical, non-invasive method of recording and analysing cardiac abnormalities. It enables a primary healthcare (PHC) clinician to detect cardiac and non-cardiac abnormalities, some potentially life-threatening. Their early detection could save a patient’s life.

Aim

The aim of this study was to evaluate the competence of generalist practitioners in ECG interpretation.

Setting

This study was conducted at the Annual Refresher Course, Council for Scientific and Industrial Research (CSIR), Pretoria.

Methods

A cross-sectional study was conducted amongst 93 generalist practitioners, using a self-administered questionnaire containing 20 ECG tracings, commonly encountered in PHC. The tracings were categorised into primary ECG parameters, ECG emergencies and common ECG abnormalities. Competence was determined by the generalist practitioner’s number of correctly interpreted ECG tracings. Data associations were computed using the Fisher’s exact test. Statistical significance was set at p ≤ 0.05.

Results

Correct heart rate calculation was achieved by 14/83 (16.9%), ECG rhythm by 7/83 (8.4%), acute antero-septal myocardial infarction (MI) by 29/83 (34.9%), atrial fibrillation by 19/83 (22.9%) and cute inferior MI by 22/83 (26.5%) generalist practitioners. No correlation was found between the practitioners’ number of years in practice and competence in ECG interpretation (p > 0.05). The total number of correct answers achieved by all practitioners was 274/1860 (14.7%).

Conclusion

The generalist practitioners had poor competency on ECG interpretation regardless of the number of years in practice. Their poor self-rating corresponded with the number of correct answers they provided. There is a need for continuous education in ECG interpretation.

A pragmatic randomised controlled trial of SAFMEDS to produce fluency in interpretation of electrocardiograms

BACKGROUND

SAFMEDS (Say-All-Fast-Minute-Every-Day-Shuffled) is a flashcard-type behavioural instructional methodology, involving one-minute learning trials that function both as practice and assessment, used to facilitate the development of fluency in a behaviour. The primary research question was whether SAFMEDS engenders improvement in performance beyond that conferred by usual teaching. A secondary research question was whether SAFMEDS is an effective method of producing fluency in Electrocardiogram (ECG) interpretation.

METHODS

A pilot study was conducted to determine sample size required to power the pragmatic randomised controlled trial (RCT). For the subsequent RCT, participants were randomly assigned to a "usual teaching" control group (n = 14) or the SAFMEDS intervention group (n = 13), with the recognition of 15 cardiac conditions on ECGs (e.g., atrial fibrillation, complete heart block) targeted. Intervention group participants' performance was tracked over eight weeks as they worked towards achieving the fluency criterion. Percentage accuracy in ECG interpretation was assessed at baseline and post-test for both groups. An ANCOVA was conducted to assess for differences in the performance of the intervention and control group at post-test while controlling for the baseline performance of participants. At post-test, the numbers of participants achieving fluency within the intervention group was examined.

RESULTS

A large effect size of SAFMEDS (partial η2 = .67) was identified when controlling for the effects of baseline performance. At post-test, the intervention group significantly outperformed (M = 61.5%; SD = 12.1%) the control group (M = 31.6%; SD = 12.5%, p < .001). In total, 7 of 13 intervention group participants achieved fluency. Participants required an average of 51.9 one-minute trials (SD = 18.8) to achieve fluency.

CONCLUSIONS

SAFMEDS offers a useful adjunct to usual teaching within medical education. Further research could assess whether learning retains, is stable, and transfers to clinical practice.

Is computer-assisted instruction more effective than other educational methods in achieving ECG competence amongst medical students and residents? A systematic review and meta-analysis

OBJECTIVES

It remains unclear whether computer-assisted instruction (CAI) is more effective than other teaching methods in acquiring and retaining ECG competence among medical students and residents.

DESIGN

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

Electronic literature searches of PubMed, databases via EBSCOhost, Scopus, Web of Science, Google Scholar and grey literature were conducted on 28 November 2017. We subsequently reviewed the citation indexes for articles identified by the search.

ELIGIBILITY CRITERIA

Studies were included if a comparative research design was used to evaluate the efficacy of CAI versus other methods of ECG instruction, as determined by the acquisition and/or retention of ECG competence of medical students and/or residents.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data from all eligible studies and assessed the risk of bias. After duplicates were removed, 559 papers were screened. Thirteen studies met the eligibility criteria. Eight studies reported sufficient data to be included in the meta-analysis.

RESULTS

In all studies, CAI was compared with face-to-face ECG instruction. There was a wide range of computer-assisted and face-to-face teaching methods. Overall, the meta-analysis found no significant difference in acquired ECG competence between those who received computer-assisted or face-to-face instruction. However, subanalyses showed that CAI in a blended learning context was better than face-to-face teaching alone, especially if trainees had unlimited access to teaching materials and/or deliberate practice with feedback. There was no conclusive evidence that CAI was better than face-to-face teaching for longer-term retention of ECG competence.

CONCLUSION

CAI was not better than face-to-face ECG teaching. However, this meta-analysis was constrained by significant heterogeneity amongst studies. Nevertheless, the finding that blended learning is more effective than face-to-face ECG teaching is important in the era of increased implementation of e-learning.

PROSPERO REGISTRATION NUMBER

CRD42017067054.

How well is each learner learning? Validity investigation of a learning curve-based assessment approach for ECG interpretation

Learning curves can support a competency-based approach to assessment for learning. When interpreting repeated assessment data displayed as learning curves, a key assessment question is: "How well is each learner learning?" We outline the validity argument and investigation relevant to this question, for a computer-based repeated assessment of competence in electrocardiogram (ECG) interpretation. We developed an on-line ECG learning program based on 292 anonymized ECGs collected from an electronic patient database. After diagnosing each ECG, participants received feedback including the computer interpretation, cardiologist's annotation, and correct diagnosis. In 2015, participants from a single institution, across a range of ECG skill levels, diagnosed at least 60 ECGs. We planned, collected and evaluated validity evidence under each inference of Kane's validity framework. For Scoring, three cardiologists' kappa for agreement on correct diagnosis was 0.92. There was a range of ECG difficulty across and within each diagnostic category. For Generalization, appropriate sampling was reflected in the inclusion of a typical clinical base rate of 39% normal ECGs. Applying generalizability theory presented unique challenges. Under the Extrapolation inference, group learning curves demonstrated expert-novice differences, performance increased with practice and the incremental phase of the learning curve reflected ongoing, effortful learning. A minority of learners had atypical learning curves. We did not collect Implications evidence. Our results support a preliminary validity argument for a learning curve assessment approach for repeated ECG interpretation with deliberate and mixed practice. This approach holds promise for providing educators and researchers, in collaboration with their learners, with deeper insights into how well each learner is learning.

Proposed In-Training Electrocardiogram Interpretation Competencies for Undergraduate and Postgraduate Trainees

Despite its importance in everyday clinical practice, the ability of physicians to interpret electrocardiograms (ECGs) is highly variable. ECG patterns are often misdiagnosed, and electrocardiographic emergencies are frequently missed, leading to adverse patient outcomes. Currently, many medical education programs lack an organized curriculum and competency assessment to ensure trainees master this essential skill. ECG patterns that were previously mentioned in literature were organized into groups from A to D based on their clinical importance and distributed among levels of training. Incremental versions of this organization were circulated among members of the International Society of Electrocardiology and the International Society of Holter and Noninvasive Electrocardiology until complete consensus was reached. We present reasonably attainable ECG interpretation competencies for undergraduate and postgraduate trainees. Previous literature suggests that methods of teaching ECG interpretation are less important and can be selected based on the available resources of each education program and student preference. The evidence clearly favors summative trainee evaluation methods, which would facilitate learning and ensure that appropriate competencies are acquired. Resources should be allocated to ensure that every trainee reaches their training milestones and should ensure that no electrocardiographic emergency (class A condition) is ever missed. We hope that these guidelines will inform medical education programs and encourage them to allocate sufficient resources and develop organized curricula. Assessments must be in place to ensure trainees acquire the level-appropriate ECG interpretation skills that are required for safe clinical practice.

What We Do and Do Not Know about Teaching Medical Image Interpretation

Educators in medical image interpretation have difficulty finding scientific evidence as to how they should design their instruction. We review and comment on 81 papers that investigated instructional design in medical image interpretation. We distinguish between studies that evaluated complete offline courses and curricula, studies that evaluated e-learning modules, and studies that evaluated specific educational interventions. Twenty-three percent of all studies evaluated the implementation of complete courses or curricula, and 44% of the studies evaluated the implementation of e-learning modules. We argue that these studies have encouraging results but provide little information for educators: too many differences exist between conditions to unambiguously attribute the learning effects to specific instructional techniques. Moreover, concepts are not uniformly defined and methodological weaknesses further limit the usefulness of evidence provided by these studies. Thirty-two percent of the studies evaluated a specific interventional technique. We discuss three theoretical frameworks that informed these studies: diagnostic reasoning, cognitive schemas and study strategies. Research on diagnostic reasoning suggests teaching students to start with non-analytic reasoning and subsequently applying analytic reasoning, but little is known on how to train non-analytic reasoning. Research on cognitive schemas investigated activities that help the development of appropriate cognitive schemas. Finally, research on study strategies supports the effectiveness of practice testing, but more study strategies could be applicable to learning medical image interpretation. Our commentary highlights the value of evaluating specific instructional techniques, but further evidence is required to optimally inform educators in medical image interpretation.