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

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.

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.