Competency in electrocardiogram interpretation among graduating medical students

How to improve medical students' ECG interpretation skills ? Multicenter survey and results of a comparative study evaluating a new educational approach

BACKGROUND

Learning to interpret electrocardiograms (ECGs) is a crucial objective in medical education. Despite its importance, errors in ECGs interpretation are common, and the optimal teaching methods have not yet been clearly established.

OBJECTIVES

To evaluate students' confidence in ECGs analysis and their opinion on current teaching methods, and to assess the effectiveness of a new ECG educational approach.

METHODS

First, we conducted a survey on ECG learning among fourth to sixth-year medical students. Second, a 5-week multicenter comparative study was conducted with fourth-year medical students during their cardiology internship. Two different teaching methods were used, assigned by center. The first group participated in 5-minutes workshops 4 times a week using a "reversed classroom" method, supervised by a cardiologist, where students took turns selecting, presenting and discussing ECGs. The control group attended a single 2-hour face-to-face ECG course. All participants completed a 30-minute ECGs analysis test at baseline and after 5 weeks.

RESULTS

Out of 401 survey respondents, the confidence levels in ECG interpretation were 3/5 (IQR 2-3) for routine situations and 2/5 (IQR 1-3) for emergency situations. Satisfaction with ECG teaching was low (2/5, IQR 1-3) and 96.3% of respondents favored more extensive ECG training. In the comparative study, 52 students from 3 medical schools were enrolled (control group: n = 27; workshop group: n = 25). Both groups showed significant improvement in exam scores from baseline to 5-week (33/100 ± 12/100 to 44/100 ± 12/100, p < 0.0001 for the control group and 36/100 ± 13/100 to 62/100 ± 12/100, p < 0.0001 for the workshop group). The improvement was significantly greater in the workshop group compared to the control group (+ 26 ± 11 vs. + 11 ± 6, p < 0.001).

CONCLUSIONS

Among French medical students who initially reported low confidence and insufficient skills in ECG interpretation, the workshop approach using a "reversed classroom" method was found to be more effective than conventional lecture-based teaching during cardiology internship.

Evaluating the impacts of digital ECG denoising on the interpretive capabilities of healthcare professionals

Aims

Electrocardiogram (ECG) interpretation is an essential skill across multiple medical disciplines; yet, studies have consistently identified deficiencies in the interpretive performance of healthcare professionals linked to a variety of educational and technological factors. Despite the established correlation between noise interference and erroneous diagnoses, research evaluating the impacts of digital denoising software on clinical ECG interpretation proficiency is lacking.

Methods and results

Forty-eight participants from a variety of medical professions and experience levels were prospectively recruited for this study. Participants' capabilities in classifying common cardiac rhythms were evaluated using a sequential blinded and semi-blinded interpretation protocol on a challenging set of single-lead ECG signals (42 × 10 s) pre- and post-denoising with robust, cloud-based ECG processing software. Participants' ECG rhythm interpretation performance was greatest when raw and denoised signals were viewed in a combined format that enabled comparative evaluation. The combined view resulted in a 4.9% increase in mean rhythm classification accuracy (raw: 75.7% ± 14.5% vs. combined: 80.6% ± 12.5%, P = 0.0087), a 6.2% improvement in mean five-point graded confidence score (raw: 4.05 ± 0.58 vs. combined: 4.30 ± 0.48, P < 0.001), and 9.7% reduction in the mean proportion of undiagnosable data (raw: 14.2% ± 8.2% vs. combined: 4.5% ± 2.4%, P < 0.001), relative to raw signals alone. Participants also had a predominantly positive perception of denoising as it related to revealing previously unseen pathologies, improving ECG readability, and reducing time to diagnosis.

Conclusion

Our findings have demonstrated that digital denoising software improves the efficacy of rhythm interpretation on single-lead ECGs, particularly when raw and denoised signals are provided in a combined viewing format, warranting further investigation into the impact of such technology on clinical decision-making and patient outcomes.

Virtual Reality Simulation for the Acquisition and Retention of Electrocardiogram Interpretation Skills: A Randomized Controlled Trial Among Undergraduate Medical Students

Introduction The electrocardiogram (ECG) is one of the most important tools in diagnosing cardiac abnormalities, particularly arrhythmias and myocardial infarction. It is one of the certifiable competencies for final-year medical undergraduate students. We determined virtual reality's effectiveness in acquiring and retaining ECG interpretation skills among medical students compared to traditional teaching. Methods One hundred and forty students were randomized into two groups. Seventy-one students (immersion group) were trained using virtual reality simulation to acquire and retain interpretation skills of normal and abnormal ECG. Sixty-nine students (traditional group) were trained in the classroom using chalk and board. The primary outcome of change in acquiring knowledge of the interpretation of ECG was determined by comparing pre and post-test scores. The secondary outcome of retention of knowledge was determined by comparing pre-test and second post-test scores conducted after eight weeks of intervention. The p-value of <0.05 was considered significant. Results Out of 140 students, 50 (35.7%) were males and 90 (64.3%) were female. The mean age of the students was 22.1 (SD 1.1), with 69.3% of them between the ages of 21 and 22 years. Mean pre-test scores for the interpretation of normal ECG among immersion and traditional groups were 9.8 (SD 8.4) and 8.3 (SD 7.5), respectively, and post-test scores for the acquisition of knowledge were 24.3 (SD 5.5) and 24.8 (SD 6.3), respectively. The post-test scores for retention skills were 25.3 (SD 5.6) and 20.7 (SD 6.9) respectively (p<0.001). The mean pre-test scores for the interpretation of abnormal ECG of both groups were 7.0 (SD 6) and 8.3 (SD 6.6), respectively. Mean post-test scores for acquiring knowledge to interpret abnormal ECG were 23.5 (SD 6.2) and 17.7 (SD 9), respectively (p<0.001), and mean post-test scores for retention of interpretation skills of abnormal ECG were 19.2 (SD - 6.9) and 13.3 (SD 10.2) respectively (p=0.001). The pairwise comparison of the immersion group indicates that all the combinations that changed in score from the pre to post-intervention time points, from pre-to-retention time, and from the post-to-retention time were significant (p<0.001). Conclusion Virtual reality teaching had a better impact on acquiring and retaining the skill for interpreting normal and abnormal electrocardiograms.

Implementing mind mapping in small-group learning to promote student engagement in the medical diagnostic curriculum: a pilot study

BACKGROUND

Medical diagnostics is a pivotal bridge curriculum that receives much less attention from undergraduates in non-clinical medicine health profession programs with less student engagement and poor performance. Mind mapping is an active learning strategy for graphically presenting radiant thinking to culture clinical reasoning. The purpose of this study was to explore whether students' comprehensive diagnostic skills are enhanced through increased student engagement by employing mind mapping.

METHODS

We implemented mind mapping in small-grouped workshops with 86 junior undergraduates from preventive medicine program, for physical diagnostic sessions including physical examination (PE) maneuver, electrocardiogram (ECG) interpretation and medical history collection. We also conducted assessments of the above skills, as well as online surveys regarding their expectation on this course, self-evaluation of mind mapping in teaching and the learning process of all the modules.

RESULTS

Group members employing mind mapping in all PE sessions obtained higher scores in the heart and lung systems during the PE maneuver exam. Similarly, groups that made more in-depth mind maps achieved higher scores on the ECG quiz. In addition, groups displaying mind maps for history taking from normal classes and reformed class exhibited greater completeness of medical history with both standardized patients and real patients, which was consistent with increased collection of accompanying symptoms. Mind mapping was valued by the majority of students for its benefits in terms of acquiring PE maneuver, theoretical knowledge, medical history collection and medical records writing, clinical reasoning, communication skills, sense of teamwork and cooperation, professionalism and humanistic literacy.

DISCUSSION

The visual feature of mind mapping evoked extensive behavioral engagement in all groups, as did cognitive and emotional engagement, as the majority of students expressed their willingness and affective reactions. In the short term, the positive feedbacks encourage growing engagement. The continuous benefits of mind mapping require long-term observation.

The spacing effect: Improving electrocardiogram interpretation

BACKGROUND

Accurate electrocardiogram (ECG) interpretation is critical for safe patient care, making this skill a necessary competency for medical school graduation. Improved long-term memory retention with repeated exposure to material is one of the most evidenced-based components of adult learning science. This curricular innovation aimed to determine if implementing spaced repetition and retrieval practice using ECG quizzes during the principal clinical year would improve ECG interpretation skills among medical students enrolled in a Longitudinal Integrated Clerkship (LIC).

APPROACH

The curricular innovation applied the spacing effect and retrieval practice. Cognitive science demonstrates enhanced long-term retention through repeated interval exposure to learned material. Studies of spaced retrieval indicate that memory retention is enhanced through tests involving effortful recall. LIC students in an intervention group were exposed to the spacing effect with periodic ECG quizzes throughout their clinical clerkship year.

EVALUATION

The results of the 17-item post-test for 140 students were analysed: LIC intervention, N = 54; block control, N = 62; and LIC control, N = 24. The ANOVA test was significant (p < 0.001). Games-Howell post hoc testing showed that the mean score in the LIC intervention group was significantly higher compared with the LIC control group (p < 0.001) and the block control group (p < 0.001). There was no significant difference between the LIC control and block control groups (p = 0.59).

IMPLICATIONS

Spaced repetition of material through ECG quizzes improved ECG interpretation skills on an ECG post-test and mitigates the forgetting curve, maintaining student competency in ECG interpretation.

The HEARTS ECG workshop: a novel approach to resident and student ECG education

OBJECTIVES

ECG interpretation is a life-saving skill in emergency medicine (EM), and a core competency in undergraduate medical curricula; however, confidence for residents/students is low. We developed a novel educational intervention-the HEARTS ECG workshop-that provides a systematic approach to ECG interpretation, teaches EM residents through the process of teaching medical students and highlights emergency management.

METHODS

We used the Kern Approach to Curriculum Development. A review of ECG education literature and a targeted needs assessment of local students/residents led to goals and objectives including systematic ECG interpretation with clinical relevance. ECGs were selected based on a national consensus of EM program directors and categorized into 5 common emergency presentations. The educational strategy included content based on HEARTS approach (Heart rate/rhythm, Electrical conduction, Axis, R-wave progression, Tall/small voltages, and ST/T changes), and methods including flipped classroom and near-peer teaching. Evaluation and feedback were based on the Kirkpatrick program evaluation. The workshop was piloted with 6 junior EM residents and 58 medical students, and repeated with nine residents and 68 students from four medical schools.

RESULTS

Residents and students agreed or strongly agreed that the workshop improved their perceived ability (100% and 95%, respectively) and confidence (77% and 88%, respectively) in interpreting ECGs. Reports of ECG interpretation causing anxiety declined from pre-workshop (61% and 83% respectively) to post-workshop (38% and 37% respectively). Residents reported behavior change: 3 months after the workshop, 92.3% reported ongoing use of the HEARTS approach clinically and through teaching medical students on shifts. Reported workshop strengths included the pre-workshop material, the clinical application, facilitator-to-learner ratio, interactivity, the ease of remembering and applying the HEARTS mnemonic, and the iterative application of the approach. Suggested changes included longitudinal sessions with graded difficulty, and allocating more time for introductory material for ease of understanding.

CONCLUSION

The HEARTS ECG workshop is an innovative pedagogical method that can be adapted for all levels of training. Future directions include integration in undergraduate medical and EM residency curricula, and workshops for physicians to update ECG interpretation skills.

Impact of an online learning by concordance program on reflection

BACKGROUND

Learning by concordance (LbC) is a recent approach that introduces learners to the complexity and uncertainty of clinical practice. Some data on LbC suggest that it stimulates reflection in future clinicians. We developed an online LbC training program on electrocardiogram (ECG) interpretation in general practice at the University of Strasbourg, France, and conducted an exploratory qualitative study to document the impact of this ECG learning-by-concordance training program on reflection in participants.

METHODS

We created 18 clinical vignettes on ECG interpretation based on a review of the literature on frequent and serious cardiovascular diseases that can be identified using an ECG in general practice. The training program was delivered online to postgraduate general practice students in two faculties of medicine. We conducted a qualitative study based on thematic analysis of two focus groups and six individual interviews. Inductive and deductive coding were performed. The five major components of reflection in the Nguyen model were used in the deductive coding: (i) thoughts and actions, (ii) attentive, critical, exploratory, and iterative processes (ACEI), (iii) underlying conceptual frame, (iv) change and (v) self.

RESULTS

Two focus groups and six individual interviews were conducted. The qualitative analysis indicated 203 codes in the focus groups and 206 codes in the individual interviews, which were divided into five groups based on the components of reflection in the Nguyen model: (i) the self; (ii) attentive, critical, exploratory, and iterative interactions with (iii) one's thoughts and actions; and (iv) a view on both the change itself and (v) the underlying conceptual frame. Inductive coding revealed interesting insights into the impact of the identity of the panel members, the absence of a scoring system and the question of uncertainty in ECG reading.

CONCLUSIONS

This study supports the claim that the use of LbC in the context of ECG interpretation could foster reflection in future general practitioners. We discuss future research avenues on instructional design of LbC and reflection.

Electrocardiogram Interpretation Competency of Medical Interns in Saudi Arabia: A Cross-Sectional Study

Objective To determine the competence of medical interns in Saudi Arabia in interpreting common ECG abnormalities, explore limitations, and facilitate solutions to the development of ECG interpretation skills in Saudi Arabia. Methods This cross-sectional study was conducted from 11 June 2022 to 3 November 2022 using the convenience stratified sampling technique among 373 medical interns (54.4% male and 45.6% female) in 15 medical colleges within Saudi Arabia. Results Almost all (91.7%) of the participants recognized the basic ECG elements, as they correctly identified normal ECG patterns. The most well-understood ECG pathologies were ventricular fibrillation, atrial fibrillation, and acute myocardial infarction, which were accurately interpreted by 69.2%, 67.8%, and 61.9% of the participants, respectively. The least understood ECG result was a pathological Q wave, which only 20.9% recognized. Most (63.5%) participants attributed their challenges in ECG interpretation to their inadequate training in college, and 57.4% of them stated that practical case-based training could best facilitate the improvement of their skills in ECG interpretation. Conclusion Most of the participants showed unsatisfactory performance in ECG interpretation. Despite their completion of advanced cardiac life support courses, their overall performance did not improve significantly. Most of them believed that their colleges did not adequately train them to read ECGs. Thus, a majority think case-based training is a key strategy for improving their ECG interpretation skills.

Evaluating a Blended Learning Model for Medical Student ECG Teaching

OBJECTIVES

The ability to interpret a 12-lead electrocardiogram (ECG) is an essential skill in inpatient and outpatient settings. In medical school, this skill is generally taught during the Internal Medicine clerkship. Blended learning is a pedagogical tool that combines different modes of information delivery, models of teaching, and learning styles combining face-to-face learning sessions with online learning. The objectives of this study were to develop a curriculum using a blended educational model including lecture, focused educational videos, flipped classroom, and team-based learning to teach a systematic approach to ECG interpretation and enhance the ability of students to identify common and life-threatening electrocardiographic abnormalities.

METHODS

Between 2016 and 2019, 349 medical students from the University of Colorado School of Medicine received the blended learning curriculum, which included an introductory lecture followed by five 30-minute sessions. These sessions encompassed preclass videos and team-based learning in a flipped-classroom design covering critical concepts in electrocardiography. A sample of 64 students completed a survey evaluating confidence in ECG interpretation skills before and after the curriculum. All of the students completed a 17-item pretest and posttest.

RESULTS

The new curriculum improved learner confidence in ECG interpretation (Wilcoxon signed rank-sum test, P < 0.001). Postcurriculum test scores showed statistically significant improvement in all of the diagnoses tested (paired Student t test, P < 0.01), the most significant gains occurring in the life-threatening tracings of ventricular fibrillation and in ventricular tachycardia.

CONCLUSIONS

Using a blended learning model with multiple educational modalities resulted in significant improvement in learners' performance and confidence in ECG interpretation.

Competency and confidence in ECG interpretation among medical students

Objectives

To assess competency and confidence in ECG interpretation in medical students across years of medical school and evaluate the associations of various factors, a curriculum change, and student confidence with ECG competency.

Methods

Four hundred and fourteen (414) third- to sixth-year medical students participated in this cross-sectional study conducted in 2019 in the Hebrew University of Jerusalem, Israel. A voluntary response sample of participants answered a validated, web-based questionnaire, composed of eight ECG strips. Participants were also asked about confidence and sources for ECG education and exposure. Competency and confidence across medical school years were compared using the ANOVA and chi-square tests.

Results

Competency was low overall (mean score, SD (standard deviation) 3.23±1.81 out of 8), and higher in sixth-year students compared to third-, fourth- and fifth-year students (4.37±1.69 vs. 2.90±1.82, 2.90±1.54, 2.50±1.56, respectively, F(3,337)=24.425, p<0.0001). There was no difference between students before and after the curriculum change. Work experience in medicine was associated with competency (odds ratio (OR), 7.97; 95% confidence interval (CI), 4.03-15.77, p<0.0001). The reported confidence level was low (median 2 out of 5) and was found to be correlated with the total score achieved (r(332)=0.5, p<0.0001).

Conclusions

Student competency was shown to be insufficient throughout medical school. Competency and confidence in ECG interpretation seem to be significantly improved by increased and repetitive exposure to ECG. Thus, strategies to facilitate better ECG skills should involve an extended focus on ECG in the undergraduate and graduate curricula and include competency-based educational programs.

Electrocardiography Interpretation Proficiency Among Medical Doctors of Different Grades in the United Kingdom

Objective: Electrocardiography interpretation is a core clinical skill for all doctors participating in emergency medical services. Given the majority of ECGs initially performed in hospital on admission are reviewed by junior doctors, and the need for life-threatening pathology to be diagnosed or excluded, further understanding of the level of competency in interpretation and factors associated with this are needed.

Methods: This was a cross-sectional, descriptive, analytical study. The data were collected using a structured questionnaire. This was comprised of two sections; the first section contained questions related to confidence, previous ECG learning and factors thought to be associated with ECG interpretation competence. The second section was an ECG quiz of 10 12-lead ECGs of varying complexity for interpretation assessment. Descriptive and inferential statistics were utilized for data analysis.

Results: Sixty-two doctors from foundation year 1 to registrar level working in acute medicine across three hospitals participated. The mean overall percentage score for the ECG quiz was 45%. No association was found between junior doctor training grade and overall score on the ECG assessment. Undergraduate and postgraduate teaching strategies also did not impact competence. Only 9.7% reported themselves as “confident” interpreting ECGs. There was a trend towards higher levels of competency among those who felt they had undergone sufficient ECG teaching and those who sought regular feedback from other clinicians.

Conclusion: This study demonstrated low overall levels of ECG interpretation competency among junior doctors in a large acute teaching NHS trust regardless of grade. Factors associated with competency remain unclear.

Educational impact of an active learning session with 6-lead mobile electrocardiography on medical students’ knowledge of cardiovascular physiology during the COVID-19 pandemic in the United States: a survey-based observational study

Mobile electrocardiogram (ECG) devices are valuable tools for teaching ECG interpretation. The primary purpose of this follow-up study was to determine if an ECG active learning session could be safely and effectively performed during the coronavirus disease 2019 (COVID-19) pandemic using a newly developed mobile 6-lead ECG device. Additionally, we examined the educational impact of these active learning sessions on student knowledge of cardiovascular physiology and the utility of the mobile 6-lead ECG device in a classroom setting. In this study, first-year medical students (MS1) performed four active learning activities using the new mobile 6-lead ECG device. Data were collected from 42 MS1s through a quantitative survey administered in September 2020. Overall, students felt the activity enhanced their understanding of the course material and that the activity was performed safely and in compliance with local COVID-19 guidelines. These results emphasize student preference for hands-on, small group learning activities in spite of the pandemic.

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.

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.

An algorithm to assist novices with electrocardiogram interpretation: Validation with the Delphi Method

PURPOSE

Electrocardiograms (ECG) are often poorly interpreted by novices and this can delay time-sensitive, critical intervention. This study aimed to assess, improve and validate a stepwise ECG algorithm designed to assist with ECG interpretation by novices by soliciting the opinions of an international cohort of expert cardiologists.

METHODS

The Delphi Method was used, and an online questionnaire was sent to an international panel of cardiologists. Experts were required to evaluate each step of the algorithm and offer comments. Feedback was analysed by the investigators, changes to the algorithm were made and these were sent back to the experts until a consensus was reached. Two rounds of the Delphi Method were required to achieve consensus.

RESULTS

Overall, 55 responses were achieved (round one = 33, round two = 22). The average agreement in round one was 90.2% with 25 changes from 124 comments. Round two achieved 93.4% agreement with 12 changes from 57 comments. The threshold for consensus was set at 90% and was confirmed as being reached by all four investigators of this study. A final algorithm was therefore established. The ECG algorithm was validated through a rigorous two-stage development and review process.

CONCLUSIONS

The algorithm was validated as a safe, informative tool for novices to use to improve ECG interpretation. Real-world user validation is now required to further improve the algorithm.

Clinically contextualised ECG interpretation: the impact of prior clinical exposure and case vignettes on ECG diagnostic accuracy

BACKGROUND

ECGs are often taught without clinical context. However, in the clinical setting, ECGs are rarely interpreted without knowing the clinical presentation. We aimed to determine whether ECG diagnostic accuracy was influenced by knowledge of the clinical context and/or prior clinical exposure to the ECG diagnosis.

METHODS

Fourth- (junior) and sixth-year (senior) medical students, as well as medical residents were invited to complete two multiple-choice question (MCQ) tests and a survey. Test 1 comprised 25 ECGs without case vignettes. Test 2, completed immediately thereafter, comprised the same 25 ECGs and MCQs, but with case vignettes for each ECG. Subsequently, participants indicated in the survey when last, during prior clinical clerkships, they have seen each of the 25 conditions tested. Eligible participants completed both tests and survey. We estimated that a minimum sample size of 165 participants would provide 80% power to detect a mean difference of 7% in test scores, considering a type 1 error of 5%.

RESULTS

This study comprised 176 participants (67 [38.1%] junior students, 55 [31.3%] senior students, 54 [30.7%] residents). Prior ECG exposure depended on their level of training, i.e., junior students were exposed to 52% of the conditions tested, senior students 63.4% and residents 96.9%. Overall, there was a marginal improvement in ECG diagnostic accuracy when the clinical context was known (Cohen's d = 0.35, p < 0.001). Gains in diagnostic accuracy were more pronounced amongst residents (Cohen's d = 0.59, p < 0.001), than senior (Cohen's d = 0.38, p < 0.001) or junior students (Cohen's d = 0.29, p < 0.001). All participants were more likely to make a correct ECG diagnosis if they reported having seen the condition during prior clinical training, whether they were provided with a case vignette (odds ratio [OR] 1.46, 95% confidence interval [CI] 1.24-1.71) or not (OR 1.58, 95% CI 1.35-1.84).

CONCLUSION

ECG interpretation using clinical vignettes devoid of real patient experiences does not appear to have as great an impact on ECG diagnostic accuracy as prior clinical exposure. However, exposure to ECGs during clinical training is largely opportunistic and haphazard. ECG training should therefore not rely on experiential learning alone, but instead be supplemented by other formal methods of instruction.

The Development of Visual Expertise in ECG Interpretation: An Eye-Tracking Augmented Re Situ Interview Approach

Phenomenon: Visual expertise in medicine involves a complex interplay between expert visual behavior patterns and higher-level cognitive processes. Previous studies of visual expertise in medicine have centered around traditionally visually intensive disciplines such as radiology and pathology. However, there is limited study of visual expertise in electrocardiogram (ECG) interpretation, a common clinical task that is associated with high error rates. This qualitatively driven multi-methods study aimed to describe differences in cognitive approaches to ECG interpretation between medical students, emergency medicine (EM) residents, and EM attending physicians. Approach: Ten medical students, 10 EM residents, and 10 EM attending physicians were recruited from one tertiary academic center to participate in this study. Participants interpreted 10 ECGs with a screen-based eye-tracking device, then underwent a subjective re situ interview augmented by playback of the participants' own gaze scan-paths via eye-tracking. Interviews were transcribed verbatim and an emergent thematic analysis was performed across participant groups. Diagnostic speed, accuracy, and heat maps of fixation distribution were collected to supplement the qualitative findings. Findings: Qualitative analysis demonstrated differences among the cohorts in three major themes: dual-process reasoning, ability to prioritize, and clinical implications. These qualitative findings were aligned with differences in visual behavior demonstrated by heat maps of fixation distribution across each ECG. More experienced participants completed ECG interpretation significantly faster and more accurately than less experienced participants. Insights: The cognitive processes related to ECG interpretation differed between novices and more experienced providers in EM. Understanding the differences in cognitive approaches to ECG interpretation between these groups may help inform best practices in teaching this ubiquitous diagnostic skill.

Mastering Electrocardiogram Interpretation Skills Through a Perceptual and Adaptive Learning Module

Although accurate interpretation of the standard 12-lead electrocardiogram (ECG) is fundamental to diagnosing heart disease, several prior studies report low accuracy rates among medical students, residents, and practicing physicians. The objective of this study was to determine if an online ECG Perceptual and Adaptive Learning Module (ECG PALM) is an efficient instrument to teach ECG interpretation. The ECG PALM consists of 415 unique ECG tracings with associated pretest, posttest, and delayed tests, each using 30 additional ECGs to gauge the effectiveness and durability of training. Between 2013 and 2015, a total of 113 third-year and 156 fourth-year medical students and 34 first-year, 41 second-year, and 37 third-year emergency medicine residents completed the PALM and associated tests. We measured two mastery criteria: accuracy, the percentage of correct interpretations, and fluency, the percentage of images interpreted accurately within 15 seconds. The ECG PALM produced statistically significant improvements (0.0001 < p < 0.0045) in student and resident performance for both accuracy (effect size = 0.9 to 3.2) and fluency (effect size = 2.5 to 3.1) following training ranging from 46 ± 24 minutes (R3s) to 88 ± 32 minutes (third-year medical students). Medical students and residents performed significantly better on a test the year following training (delayed test) than those without prior ECG PALM training (pretest). The fluency of R3 residents in classifying the 15 diagnostic categories was less than 60% for nine of the 15 diagnoses and greater than 80% for only one. Following PALM training, fluency was higher than 80% for seven of the 15 categories and less than 60% for only two categories. Accuracy in recognizing ST-elevation myocardial infarctions (STEMIs) was high both before and after PALM training for R3s, but fluency was only 64% for anterior STEMIs on the pretest, increasing to 93% following PALM training. These observations suggest that the ECG PALM is an effective and durable supplemental tool for developing mastery in interpreting common ECG abnormalities.

EE-6S: an integrated approach for introducing early clinical exposure in the new Egyptian medical curriculum

The electrocardiogram (ECG) is the primary diagnostic tool in cardiovascular diseases. Hence its interpretation is a core competency in medicine, where obvious deficiencies have been reported among learners. The aim of this study was to introduce the fundamentals of ECG knowledge and interpretation through early clinical exposure (ECE) based on a six-step approach for preclinical students (n = 110) and to study its influence on their knowledge and interpretation skills thereafter. The first step employed a blended learning format using didactic lectures on normal and pathological ECGs, each preceded by preinstructional videos. The second step focused on psychomotor skills and utilized laboratory exercises for ECG recording and interpretation. The third step focused on vertical integration, where the clinical relevance of the procedure was established with integrated lectures. The fourth step used the Moodle platform, where opportunities for peer interactions and clarifications by clinical faculty were made available. The fifth step incorporated clinical and diagnostic reasoning through cardiology ward visits and interpretation of patient ECGs. The sixth step was designed for critical thinking and problem solving through case-based discussions with peers and faculty. Students were assessed with multiple-choice questions and objective structured practical examination. Learner perceptions of the approach were evaluated with a feedback questionnaire and focus group discussion. Statistical analysis showed that ECE through a six-step approach significantly enhanced knowledge and interpretation of ECG as evidenced by the pre- and posttest scores. Analysis of the focus group data revealed that learner engagement and skills of critical thinking were enhanced along with diagnostic and clinical reasoning.

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.

Determining electrocardiography training priorities for medical students using a modified Delphi method

BACKGROUND

Although electrocardiography is considered a core learning outcome for medical students, there is currently little curricular guidance for undergraduate ECG training. Owing to the absence of expert consensus on undergraduate ECG teaching, curricular content is subject to individual opinion. The aim of this modified Delphi study was to establish expert consensus amongst content and context experts on an ECG curriculum for medical students.

METHODS

The Delphi technique, an established method of obtaining consensus, was used to develop an undergraduate ECG curriculum. Specialists involved in ECG teaching were invited to complete three rounds of online surveys. An undergraduate ECG curriculum was formulated from the topics of ECG instruction for which consensus (i.e. ≥75% agreement) was achieved.

RESULTS

The panellists (n = 131) had a wide range of expertise (42.8% Internal Medicine, 22.9% Cardiology, 16% Family Medicine, 13.7% Emergency Medicine and 4.6% Health Professions Education). Topics that reached consensus to be included in the undergraduate ECG curriculum were classified under technical aspects of performing ECGs, basic ECG analysis, recognition of the normal ECG and abnormal rhythms and waveforms and using electrocardiography as part of a clinical diagnosis. This study emphasises that ECG teaching should be framed within the clinical context. Course conveners should not overload students with complex and voluminous content, but rather focus on commonly encountered and life-threatening conditions, where accurate diagnosis impacts on patient outcome. A list of 23 "must know" ECG diagnoses is therefore proposed.

CONCLUSION

A multidisciplinary expert panel reached consensus on the ECG training priorities for medical students.

A qualitative study on negative attitude toward electrocardiogram learning among undergraduate medical students

Objective:

Negative affect state toward learning has a substantial impact on the learning process, academic performance, and practice of a particular subject, but such attitude toward electrocardiogram (ECG) learning has still received relatively little attention in medical education research. In spite of the significant emphasis in investigating ECG teaching method, the educators would not be able to address ECG incompetency without understanding the negative perception and attitude toward ECG learning. The purpose of this study was to assess the undergraduate students' difficulties in ECG learning and hence help educators design appropriate ECG learning curriculum to instill competent skill in ECG interpretation based on this outcome.

Materials and Methods:

A total of 324 undergraduate preclinical (year 2) and clinical (year 3–5) medical students participated in this study. The research design used thematic analysis of an open-ended questionnaire to analyze the qualitative data.

Results:

The thematic analysis detected five major emergent themes: lack of remembering (18.2%), lack of understanding (28.4%), difficulty in applying (3.6%), difficulty in analysis (15.1%), and difficulty in interpretation (17.8%), of which addressing these challenges could be taken as a foundation step upon which medical educators put an emphasis on in order to improve ECG teaching and learning.

Conclusion:

Negative attitude toward ECG learning poses a serious threat to acquire competency in ECG interpretation skill. The concept of student's memorizing ECG is not a correct approach; instead, understanding the concept and vector analysis is an elementary key for mastering ECG interpretation skill. The finding of this study sheds light into a better understanding of medical students' deficient points of ECG learning in parallel with taxonomy of cognitive domain and enables the medical teachers to come up with effective and innovative strategies for innovative ECG learning in an undergraduate medical curriculum.

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.

The Simulated Cardiology Clinic: A Standardized Patient Exercise Supporting Medical Students' Biomedical Knowledge and Clinical Skills Integration

INTRODUCTION

Development of cardiac disease-related diagnostic skills-including hypothesis-driven data gathering, heart sound interpretation, and ECG interpretation-is an important component of medical student training. Prior studies indicate trainees' performance of these skills is limited. Simulation provides students with opportunities to practice integrating their developing knowledge in a relevant clinical context. We developed a simulated clinic activity for second-year medical students consisting of standardized patient (SP) cases representing cardiovascular (CV) diseases.

METHODS

Student small groups rotated through four SP encounters. For each case, one student performed the history, after which the whole small group listened to audio files of heart sounds, interpreted an ECG, and collaboratively developed a prioritized differential diagnosis. The CV course director met with students for a large-group debrief, highlighting key learning points. We collected learners' evaluations of the event through an online survey.

RESULTS

Of students, 276 participated in this activity over the course of 2 years. Nearly all students assessed the activity as extremely or quite effective for applying learning content from the CV course (97%, 2018; 93%, 2019), and for practicing how to approach chest pain, shortness of breath, palpitations, and fatigue (100%, 2018; 95%, 2019). The most helpful aspects were reinforcement of CV disease illness scripts, hypothesis-driven data gathering practice, ECG interpretation, and applying knowledge and skills in a realistic context.

DISCUSSION

SP encounters representing CV conditions can effectively provide opportunities for students to integrate basic science knowledge and clinical skills. Students assessed the activity as helpful and engaging.

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.

Electrocardiogram Interpretation Competency Among Paramedic Students

BACKGROUND

Electrocardiography is an essential emergency tool used in the pre-hospital setting. However, no studies have yet assessed electrocardiogram (ECG) interpretation among emergency medical services (EMS) students in Saudi Arabia. This study aimed to determine the ECG interpretation competency of paramedic students.

METHODOLOGY

Cross-sectional, single-center study, a pre-validated, self-administered, two-part questionnaire first created by Coll-Badell et al was used to assess the ECG interpretation competency of paramedic students at Prince Sultan College for Emergency Medical Services (PSCEMS) in King Saud University. Participant data were collected and analyzed to identify factors associated with improved competency.

RESULTS

All students of PSCEMS were included, and 137 of 248 paramedic students completed the questionnaire (55% response rate); 88 students (64.2%) scored >7.5 points, indicating competency in (ECG) interpretation. Factors such as grade point average (GPA) (>3.5) and enrollment in cardiology and advanced cardiac life support courses were found to be significantly associated with competency (p<0.001).

CONCLUSION

The majority of paramedic students were found to be competent in ECG interpretation. GPA and enrollment in cardiology and advanced cardiac life support courses were significantly associated with improved competency.

Electrocardiography Interpretation Competency of Medical Interns: Experience from Two Ethiopian Medical Schools

Background

Electrocardiography (ECG) is the graphical display of electrical potential differences of an electric field originating in the heart. Interpretation of ECG is a core clinical skill in the department of emergency medicine. The main aim of this survey was to assess competency of ECG interpretation among 2018 graduating class medical students in Addis Ababa University and Haramaya University. Methodology. A cross-sectional survey was conducted on medical interns at Addis Ababa University and Haramaya University. Data had been collected from October 01, 2018, to October 30, 2018, by using structured questionnaires. Data were entered, cleaned, edited, and analyzed by using SPSS version 25.0 statistical software. Descriptive statistics, cross-tabs, chi-squared test, Mann–Whitney U test, and binary logistic regression were utilized.

Results

Two-hundred and two graduating medical students were involved on this survey, out of which 61.3% (95% CI 56.3–66.3%) and 32.75% (95% CI 28.25–37.25) were able to correctly interpret the primary ECG parameters and the arrest rhythm of ECG abnormalities, respectively. The ability to detect from common emergency ECG abnormalities of anterioseptal ST segment elevation myocardial infraction, atrial fibrillation, and first-degree atrioventricular block was 42.6%, 39.1%, and 32.1%, respectively.

Conclusion

This survey showed graduating medical students had low competency in ECG interpretations.

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.

Orderly display of limb lead ECGs raises Chinese intern's diagnostic accuracy when determining frontal plane QRS axis

BACKGROUND

There is limited information on whether the orderly display of limb lead ECGs (electrocardiograms) can facilitate students to determine frontal plane QRS complex wave electrical axis.

OBJECTIVES

The study investigated whether the orderly display of limb lead ECGs can raise Chinese undergraduate intern's diagnostic accuracy when determining frontal plane axis.

DESIGN

A total of 147 fifth-year undergraduate interns aged between 21 and 25 years were randomly arranged into 2 groups: one group was given classically displayed ECGs of limb leads while the other group was given orderly displayed ECGs of limb leads. They were then taught to determine frontal plane axis with one of the above displays. The intern's diagnostic accuracy and time used were measured.

RESULTS

After teaching, the orderly display can more effectively raise diagnostic accuracy when determining axis as compared to the classical display (76.65 ± 23.16% vs. 68.88 ± 23.21%, P < 0.05), although diagnostic accuracy in axis determination was improved in both groups as compared to the axis determination at baseline (all P < 0.05).

CONCLUSIONS

Orderly display of limb lead ECGs may raise Chinese intern's diagnostic accuracy when determining frontal plane axis.

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.

A qualitative study on the development and rectification of advanced medical students' misconceptions about the physiological electrocardiogram (ECG)

Purpose: The study takes a qualitative and explorative approach to capture the concepts that German medical students have of the physiological electrocardiogram (ECG) which they acquired during their preclinical training. These concepts are then considered for possible misconceptions. Afterwards a theory-based intervention which allows subjects to see the connection of the curve progression with the spatial spreading of excitation (animated vector loop) is put to the test. Methods: In the course of a diagnosis of learning potentials, individual students participated in problem-centred, guided interviews. The developed intervention was tested in separately conducted teaching experiments using thinking aloud protocols. The data evaluation was done through qualitative content analysis. Based on the conceptual metaphor theory, conceptions and their underlying embodied cognition were analysed. Results: One of the subjects' typical misinterpretations is taking the progression of the ECG tracing for a mere increase and decrease of the myocardium's electrical activity, rather than connecting it with its spatial and temporal aspects. The data evaluation has shown that the newly developed theory-based intervention can lead to re-learning. Reconstructed metaphorical concepts illustrate this process of understanding. It is exemplarily shown how, through the course of the interviews, students are enabled to appropriately explain ECGs as the two-dimensional representation of the spatial excitation propagation in the heart. Conclusion: By capturing typical misconceptions of the physiological electrocardiogram and demonstrating interventions that support learning, the study provides a contribution to comprehensive learning which can be used in the basic education of medical students.

Quantifying the medical student learning curve for ECG rhythm strip interpretation using deliberate practice

Objectives: Obtaining competency in medical skills such as interpretation of electrocardiograms (ECGs) requires repeated practice and feedback. Structured repeated practice and feedback for ECGs is likely not provided to most medical students, so skill development is dependent on opportunistic training during clinical rotations. Our aim was to describe: the amount of deliberate practice completed for learning ECG rhythm strip diagnoses in first year medical students, the learning curve for rhythm strip diagnosis, and student experiences with deliberate practice. Methods: First year medical students from two medical schools were provided with online rhythm strip practice cases. Diagnostic accuracy was measured throughout practice, and students were provided feedback for every case they completed. Total cases practiced and time spent practicing were correlated with their performance during practice and on an exam. Results: 314 of 384 (82%) students consented. The mean number of ECGs each student practiced was 59 (range 0-280), representing 18,466 total instances of deliberate practice. We generated mathematical models that accurately correlated both the number of cases practiced and time spent practicing, with diagnostic accuracy on an exam (p<0.001). For example, students would need to spend on average of 112 minutes and complete 34 practice cases to obtain 75% on an ECG rhythm strip exam. Student satisfaction was high using the online cases. Conclusions: We succeeded in delivering deliberate practice for ECG rhythm strip interpretation to a large cohort of students at 2 medical schools. We quantified a learning curve that estimates the number of cases and practice time required to achieve pre-determined levels of diagnostic accuracy. This data can help inform a competency-based approach to curriculum development.

Why Medical Students Choose to Use or Not to Use a Web-Based Electrocardiogram Learning Resource: Mixed Methods Study

BACKGROUND

Electrocardiogram (ECG) interpretation is a core competence and can make a significant difference to patient outcomes. However, ECG interpretation is a complex skill to learn, and research has showed that students often lack enough competence. Web-based learning has been shown to be effective. However, little is known regarding why and how students use Web-based learning when offered in a blended learning situation.

OBJECTIVE

The aim of this paper was to study students' use of Web-based ECG learning resources which has not previously been studied in relation to study strategies.

METHODS

A qualitative explanatory design using mixed methods was adopted to explore how medical students reason around their choice to use or not to use a Web-based ECG learning resource. Overall, 15 of 33 undergraduate medical students attending a course in clinical medicine were interviewed. Data on usage of the resource were obtained via the learning management system for all students. At the final examination, all the students answered a questionnaire on study strategies and questions about internet access and estimated their own skills in ECG interpretation. Furthermore, study strategies and use patterns were correlated with results from an ECG Objective Structured Clinical Examination (OSCE) and a written course examination.

RESULTS

In total, 2 themes were central in the students' reasoning about usage of Web-based ECG: assessment of learning needs and planning according to learning goals. Reasons for using the Web resource were to train in skills, regarding it as a valuable complement to books and lectures. The main reasons for not using the resource were believing they already had good enough skills and a lack of awareness of its availability. Usage data showed that 21 students (63%) used the Web resource. Of these, 11 were minimal users and 10 were major users based on usage activity. Large variations were found in the time spent in different functional parts of the resource. No differences were found between users and nonusers regarding the OSCE score, final examination score, self-estimate of knowledge, or favoring self-regulated learning.

CONCLUSIONS

To use or not to use a Web-based ECG learning resource is largely based on self-regulated learning aspects. Decisions to use such a resource are based on multifactorial aspects such as experiences during clinical rotations, former study experiences, and perceived learning needs. The students' own judgment of whether there was a need for a Web-based resource to achieve the learning goals and to pass the examination was crucial for their decisions to use it or not. An increased understanding of students' regulation of learning and awareness of variations in their ECG learning needs can contribute to the improvement of course design for blended learning of ECG contexts for medical students.

An evaluation study on gamified online learning experiences and its acceptance among medical students

Objective:

The successful application of gamification in different educational settings shows that the use of gamification in medical education may be an effective solution. Even though many studies have been conducted to investigate the efficacy of the integration of gamification to different education curriculums, few studies have examined the reactions, behaviors, and attitudes of learners toward the use of gamification in medical education. Hence, this study aimed to evaluate the medical students’ learning experience and acceptance of the use of gamification for the delivery of electrocardiogram lessons.

Materials and Methods:

A qualitative research method was used to generate findings in this study. The data collection methods included focus group discussions and interviews. Triangulation methods were used to ensure the validity and reliability of the qualitative data analyzed in this study. The thematic analysis of the data collected in this study helped to garner insights into the perception of participants and experts about the use of GaMed@^™ for the delivery of ECG lessons.

Results:

A total number of 32 medical students and four experts in the fields of user experience, communication, social psychology, and game design participated in this study. The findings showed that in spite of the negative reports about the user experience and application of GaMed^@™, the participants and experts affirmed its positive impact on the increased motivation and engagement of users.

Conclusions:

The impact of this concept can be maximized by tailoring the game design to foster-positive learning attributes, behaviors, and outcomes in students. However, further research studies must be conducted to investigate the impact of gamification designs on specific learning outcomes in students.

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.

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

INTRODUCTION

Although ECG interpretation is an essential skill in clinical medicine, medical students and residents often lack ECG competence. Novel teaching methods are increasingly being implemented and investigated to improve ECG training. Computer-assisted instruction is one such method under investigation; however, its efficacy in achieving better ECG competence among medical students and residents remains uncertain.

METHODS AND ANALYSIS

This article describes the protocol for a systematic review and meta-analysis that will compare the effectiveness of computer-assisted instruction with other teaching methods used for the ECG training of medical students and residents. Only studies with a comparative research design will be considered. Articles will be searched for in electronic databases (PubMed, Scopus, Web of Science, Academic Search Premier, CINAHL, PsycINFO, Education Resources Information Center, Africa-Wide Information and Teacher Reference Center). In addition, we will review citation indexes and conduct a grey literature search. Data extraction will be done on articles that met the predefined eligibility criteria. A descriptive analysis of the different teaching modalities will be provided and their educational impact will be assessed in terms of effect size and the modified version of Kirkpatrick framework for the evaluation of educational interventions. This systematic review aims to provide evidence as to whether computer-assisted instruction is an effective teaching modality for ECG training. It is hoped that the information garnered from this systematic review will assist in future curricular development and improve ECG training.

ETHICS AND DISSEMINATION

As this research is a systematic review of published literature, ethical approval is not required. The results will be reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement and will be submitted to a peer-reviewed journal. The protocol and systematic review will be included in a PhD dissertation.

PROSPERO REGISTRATION NUMBER

CRD42017067054; Pre-results.

Computer model for the cardiovascular system: development of an e-learning tool for teaching of medical students

BACKGROUND

This study combined themes in cardiovascular modelling, clinical cardiology and e-learning to create an on-line environment that would assist undergraduate medical students in understanding key physiological and pathophysiological processes in the cardiovascular system.

METHODS

An interactive on-line environment was developed incorporating a lumped-parameter mathematical model of the human cardiovascular system. The model outputs were used to characterise the progression of key disease processes and allowed students to classify disease severity with the aim of improving their understanding of abnormal physiology in a clinical context. Access to the on-line environment was offered to students at all stages of undergraduate training as an adjunct to routine lectures and tutorials in cardiac pathophysiology. Student feedback was collected on this novel on-line material in the course of routine audits of teaching delivery.

RESULTS

Medical students, irrespective of their stage of undergraduate training, reported that they found the models and the environment interesting and a positive experience. After exposure to the environment, there was a statistically significant improvement in student performance on a series of 6 questions based on cardiovascular medicine, with a 33% and 22% increase in the number of questions answered correctly, p < 0.0001 and p < 0.001 respectively.

CONCLUSIONS

Considerable improvement was found in students' knowledge and understanding during assessment after exposure to the e-learning environment. Opportunities exist for development of similar environments in other fields of medicine, refinement of the existing environment and further engagement with student cohorts. This work combines some exciting and developing fields in medical education, but routine adoption of these types of tool will be possible only with the engagement of all stake-holders, from educationalists, clinicians, modellers to, most importantly, medical students.

Competency in ECG Interpretation Among Medical Students

Background

Electrocardiogram (ECG) is commonly used in diagnosis of heart diseases, including many life-threatening disorders. We aimed to assess skills in ECG interpretation among Polish medical students and to analyze the determinants of these skills.

Material/Methods

Undergraduates from all Polish medical schools were asked to complete a web-based survey containing 18 ECG strips. Questions concerned primary ECG parameters (rate, rhythm, and axis), emergencies, and common ECG abnormalities. Analysis was restricted to students in their clinical years (4^th–6^th), and students in their preclinical years (1^st–3^rd) were used as controls.

Results

We enrolled 536 medical students (females: n=299; 55.8%), aged 19 to 31 (23±1.6) years from all Polish medical schools. Most (72%) were in their clinical years. The overall rate of good response was better in students in years 4^th–5^th than those in years 1^st–3^rd (66% vs. 56%; p<0.0001). Competency in ECG interpretation was higher in students who reported ECG self-learning (69% vs. 62%; p<0.0001) but no difference was found between students who attended or did not attend regular ECG classes (66% vs. 66%; p=0.99). On multivariable analysis (p<0.0001), being in clinical years (OR: 2.45 [1.35–4.46] and self-learning (OR: 2.44 [1.46–4.08]) determined competency in ECG interpretation.

Conclusions

Polish medical students in their clinical years have a good level of competency in interpreting the primary ECG parameters, but their ability to recognize ECG signs of emergencies and common heart abnormalities is low. ECG interpretation skills are determined by self-education but not by attendance at regular ECG classes. Our results indicate qualitative and quantitative deficiencies in teaching ECG interpretation at medical schools.

Teaching the interpretation of electrocardiograms: which method is best?

BACKGROUND

Electrocardiogram (ECG) interpretation is poorly performed at undergraduate and post-graduate level. Incorrect ECG interpretation can lead to serious clinical error. Despite the incorporation of computerized ECG interpretation software into modern ECG machines, the sensitivity and specificity of current technology remain poor, emphasizing the on-going need for doctors to perform ECG interpretation accurately.

PURPOSE

This is the first review in this important area and aims to critically evaluate the current literature in relation to the optimal format and method of teaching ECG interpretation at undergraduate and postgraduate level.

CONCLUSIONS

No single method or format of teaching is most effective in delivering ECG interpretation skills; however, self-directed learning appears to be associated with poorer interpretation competence. Summative in preference to formative assessment is associated with improved interpretation competence. Web-based learning offers a promising modern approach to learning ECG interpretation, though caution must be exercised in accessing user-uploaded content to supplement learning.