Elsevier

Journal of Electrocardiology

Volume 49, Issue 1, January–February 2016, Pages 7-12
Journal of Electrocardiology

How can we improve teaching of ECG interpretation skills? Findings from a prospective randomised trial

https://doi.org/10.1016/j.jelectrocard.2015.10.004Get rights and content

Highlights

  • Electrocardiogram interpretation is not adequately taught in many medical schools.

  • The ideal teaching format to achieve a good learning outcome is yet unknown.

  • We found no medium-term impact of teaching intensity on ECG interpretation skills.

  • Medium-term retention was enhanced by summative (vs. formative) exams.

  • ECG teaching should be accompanied by well-designed summative exams.

Abstract

Background

There is an ongoing debate on how ECG interpretation should be taught during undergraduate medical training. This study addressed the impact of teaching format, examination consequences and student motivation on skills retention.

Methods

A total of 493 fourth-year medical students participated in a six-group, partially randomised trial. Students received three levels of teaching intensity: self-directed learning (2 groups), lectures (2 groups) or small-group peer-teaching (2 groups). On each level of teaching intensity, end-of-course written examinations (ECG exit exam) were summative in one group and formative in the other. Learning outcome was assessed in a retention test two months later.

Results

Retention test scores were predicted by summative assessments (adjusted beta 4.08; 95% CI 1.39–6.78) but not by the type of teaching. Overall performance levels and motivation did not predict performance decrease or skills retention.

Conclusions

Summative assessments increase medium-term retention of ECG interpretation skills, irrespective of instructional format.

Introduction

Electrocardiogram (ECG) interpretation is an important clinical skill as it allows rapid diagnosis of potentially life-threatening diseases [1]. According to the European Society of Cardiology’s guideline for the management of acute myocardial infarction [2], the time taken between the first medical contact and the recording of the first ECG is a good index of the quality of care and should not exceed 10 min. In addition to swiftness, accuracy of the diagnosis derived from an ECG tracing is key to patient outcome [3]. Given that cardiovascular disease is highly prevalent [4], physicians of any specialty need to be familiar with the basic principles of ECG interpretation and must be capable of identifying important diagnoses. However, concerns have been raised that in many countries physicians lack these basic skills [5], [6]. One potential reason for this may be a failure of medical education to equip physicians with the knowledge and skills required to interpret an ECG. In fact, a recent survey among German medical school graduates revealed that 60% felt inadequately prepared for post-graduate training. Specifically, student replies indicated deficits in the ability to read an ECG [7]. Similar findings have been reported for graduates in New Zealand [8].

Numerous studies have addressed the question of how best to teach ECG interpretation skills [9], [10], [11], [12]. A recent review of these studies [13] concluded that based on the available evidence, ‘no single method or format of teaching is most effective in delivering ECG interpretation skills’. The authors noted that in most studies, learning outcome was assessed either shortly after or immediately after teaching and called for more research on the impact of teaching interventions on medium- and long-term skills retention.

Recent research [14] indicated that the consequences of a final exam (i.e. whether it generates a grade and can be failed (‘summative’) or just provides some feedback (‘formative’)) might outweigh any effect of teaching interventions carefully tailored to help students learn how to read an ECG. However, in that study students were aware of exam consequences, and it may be hypothesised that students taking a formative exam could have scored higher but did not feel incentivised to put much effort into the exam as they could not fail it. In addition, this study only assessed short-term learning outcome.

The primary aim of this study was to examine the effect of teaching intensity (peer teaching, lectures or self-directed learning, SDL) and examination consequences (summative versus formative) on medium-term retention of ECG interpretation skills (two months after the end of teaching). In addition, we aimed at identifying predictors of the change in student performance levels between the end of the teaching module and the retention test. We hypothesised summative exams to have a significant effect on skill retention but expected more intensive teaching to be associated with a lesser degree of performance decline towards the retention test.

Section snippets

Study design

This is a follow-up study of an earlier trial on the effect of teaching interventions and exam consequences on short-term learning outcome regarding ECG interpretation skills. Details on the design of this six-group (3 × 2), partially randomised and single-blinded trial can be found elsewhere [14]. In brief, four consecutive cohorts of fourth-year medical students enrolled in a six-week cardio-respiratory module at Göttingen Medical School were included in the trial. All students were provided

Results

A total of 565 students were eligible for study participation, and 564 provided written consent to participate. Only students with complete data on all three ECG exams (n = 493) were included in the final analysis, and their characteristics are given in Table 1. The final study sample differs from that in our earlier trial [14] in that a total of 41 students did not take the retention test. Students in the six groups differed significantly with regard to performance in the ECG entry exam as well

Discussion

In this study, we found a significant effect of summative exams on medium-term retention of ECG interpretation skills. Contrary to our expectations, more intensive teaching was not associated with improved outcome in the retention test. These effects remained after adjusting for relevant baseline predictors including motivation to learn and general performance levels. The medium- relative to the short-term effect of summative assessments was attenuated, which was illustrated by the greater

Conclusions

This study demonstrated a significant effect of summative assessments on medium-term retention of ECG interpretation skills. Compared to self-directed learning, more intensive teaching did not increase performance levels in the retention test. The substantial decline in performance observed over an 8-week period was independent of overall performance levels. These findings have implications for the design of ECG teaching and assessment interventions.

Conflicts of interest

None.

Funding and acknowledgements

We did not receive any funding for this study. We would like to thank all medical students who devoted their time to this study.

References (27)

  • N.A. Lever et al.

    Are our medical graduates in New Zealand safe and accurate in ECG interpretation?

    N Z Med J

    (2009)
  • S.A. Mahler et al.

    Techniques for teaching electrocardiogram interpretation: self-directed learning is less effective than a workshop or lecture

    Med Educ

    (2011)
  • T. Raupach et al.

    Impact of teaching and assessment format on electrocardiogram interpretation skills

    Med Educ

    (2010)
  • Cited by (27)

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

      2022, Nurse Education Today
      Citation Excerpt :

      Kamble et al. (2019) reported the effects of peer-assisted teaching methods in fostering learning the physiological basis of electrocardiography among first-year medical graduate students. However, in another study, there was no difference in ECG interpretation ability among participants in self-directed learning, lecture, and small group peer education groups (Raupach et al., 2016). Web-based education and peer learning are effective teaching and learning methods that can cultivate and maintain ECG interpretation competency through deliberate practice and cooperative learning.

    • A new algorithm for arrhythmia interpretation

      2017, Journal of Electrocardiology
      Citation Excerpt :

      The validity analysis of the test was based on ‘consequences’ in which the final scores of the interns in the two groups were compared where the only difference in these two groups is the use of the algorithm in group A [27,28]. This approach is a common and widely used method for evaluating the consequence of a change in an education system [1,13,17,29]. The average scores for each group were 18.6/20 (93%) for group A (medical interns trained using the algorithm) and 12.3/20 (62%) for group B (medical interns trained without the algorithm).

    • Computer-Interpreted Electrocardiograms: Benefits and Limitations

      2017, Journal of the American College of Cardiology
      Citation Excerpt :

      However, repeated assessments, tested by a final examination, increase medium-term retention of ECG interpretation skills, whatever the instruction format. Continuous ECG training, coupled with appropriate examinations should also be done at the post-graduate level (55). Standardization in applied algorithms and uniformization of diagnostic criteria and statements have been proposed (56).

    • A computer-human interaction model to improve the diagnostic accuracy and clinical decision-making during 12-lead electrocardiogram interpretation

      2016, Journal of Biomedical Informatics
      Citation Excerpt :

      In some institutions, ECG reporting is often documented using checklists. Such checklists do vary regarding their content and sequence of ‘checks’ depending on the institution, however they generally follow a common sequence [8,9,15–19]. The typical sequence involves: (1) heart rate, (2) rhythm analysis, (3) cardiac axis, (4) conduction times, (5) morphological features, and (6) final diagnoses.

    • Teaching crucial skills: An electrocardiogram teaching module for medical students

      2016, Journal of Electrocardiology
      Citation Excerpt :

      One theme that has emerged from a variety of strategies is that the repetition of material may be more important than its presentation [13]. One study found that assessing learners' knowledge (e.g., whether or not the test would count for anything) was significantly associated with improved performance [14]; others found that a summative examination drove learning motivations [15,16]. At our institution, the traditional medical school teaching mode is characterized by concentrated, yet integrated, basic science courses during the first year, followed by second year clinical clerkships with characteristically steep learning curves and intense self-study [17].

    View all citing articles on Scopus
    View full text