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Electrocardiogram Education: Innovative Didactic Methods Used by an Electrophysiologist to Enhance Education of ECG Interpretation at a Large Medical School
Abstract
Electrocardiogram (ECG) interpretation is an essential component of medical school education. One electrophysiologist has helped transform ECG education by using multiple in-person and virtual teaching methods at a large medical school with locations in Arkansas and New York. This brief paper reviews some of the different techniques and activities of this ECG medical education approach. Although the methods herein apply to medical students, they could also be applied to clinicians and allied staff in electrophysiology laboratories, programs, and device clinics.
Despite the importance of learning ECG interpretation in medical school, there have been widespread deficiencies reported in graduating medical students’ ability to interpret ECGs.1-4 A study published by Lee et al showed that 49% of missed acute myocardial infarctions in an emergency room setting could have been diagnosed through improved ECG interpretation skills.5 This underscores the need to enhance ECG education. This article discusses various novel methods used by the New York Institute of Technology College of Osteopathic Medicine (NYITCOM) to improve ECG analysis and interpretation for students.
Traditionally, ECG interpretation is taught in an in-person lecture setting. However, research has shown that a blended learning approach that combines lectures supplemented with web applications achieves better levels of ECG competence and retention in medical students versus conventional teaching.6,7 Virtual education extends outreach to students, allows for flexibility and diversification in the educational experience, is cost effective8, and may improve long-term retention of ECG reading in medical students. The potential benefits and drawbacks of virtual education have become largely apparent in the COVID-19 era. Hybrid education may serve as a model for educating the future generation of medical students about ECG interpretation.
To date, several studies have discussed alternative methods of ECG training, including web-based online modules, self-directed learning, and concept mapping, or hierarchical visual representations of abstract concepts and relationships.7-11 These curriculum developments have been shown to improve medical students’ ability to read and interpret ECGs.9-12 Only one other study thus far has looked at the utility of a live web-based interactive workshop for teaching ECGs.13 Moreover, few prior studies have examined the effect of various ECG teaching methods on retention. Importantly, information gained from teaching medical students may be applied to other healthcare professionals, including nurses, physician assistants, electrophysiology staff, and device clinic staff.
ECG Teaching at a Large Medical School Comes in Many Different Forms
NYITCOM is a large osteopathic medical school with campuses in Long Island, New York, and Jonesboro, Arkansas. The Long Island Heart Rhythm Center is also located on the NYITCOM campus. During his tenure, electrophysiologist Dr. Todd Cohen, who serves as Chief of Cardiology and Director of Medical Device Innovation at NYITCOM, has utilized various methods of teaching ECG analysis and interpretation. These opportunities began over two years ago and are open to current students. They include annual synchronous lectures (virtual and in-person), annual virtual asynchronous lectures, weekly in-person interactive workshops, weekly virtual interactive workshops, and a thorough review of patient ECGs during cardiology clinic and telehealth encounters. In addition, Dr. Cohen employs innovative hybrid didactic models by combining several of the aforementioned methods. These teaching methods are listed in Table 1.
Several educational modalities were already in use to teach ECGs before the emergence of the COVID-19 pandemic. Most first- and second-year medical students at NYITCOM were enrolled in the Lecture-Discussion-Based (LDB) track and learned how to interpret ECGs primarily through a series of presentations given in this lecture format during their second year. These lectures were conducted in-person; additionally, students had the option to watch the lectures asynchronously. In-person and Zoom interactive workshops were conducted at the NYITCOM Academic Health Care Centers (Old Westbury, NY, and Central Islip, NY) for third- and fourth-year medical students on their family medicine and pediatrics rotations. During the workshops, a series of 4 weekly sessions took place in which Dr. Cohen taught basic ECG reading skills, presenting several 12-lead practice ECGs for students. While some of the students were unable to attend the workshops partially or entirely due to clinical duties, students also had the opportunity to learn ECGs by participating in the cardiology clinic at NYITCOM and reviewing ECGs with Dr. Cohen in connection with various clinical cases.
ECG Learning During the COVID-19 Pandemic
During the pandemic, the expanded use of Zoom enhanced access to extracurricular ECG education. While the workshops mentioned above were mandatory for some students, a wide array of students participated voluntarily, including students who had lost their rotations due to the pandemic. As lectures were no longer conducted in-person, asynchronous prerecorded lectures were given to all second-year students studying the cardiovascular system. These included four prerecorded ~45-minute lectures, led by an academic scholar under Dr. Cohen’s supervision, reviewing the core concepts of ECGs and board-relevant ECG interpretation skills.
The material covered in each of these lectures included the following topics:
1. Basic components of ECGs;
2. Interpretation of EKG leads, vectors, and intervals;
3. Atrial and ventricular arrhythmias;
4. Conduction blocks, pacemakers, and electrolyte disturbances.
As NYITCOM later began to create additional opportunities for in-person learning, hybrid teaching models were also still used for ECG education. For example, the in-clinic ECG teaching method was available in-person as well as virtually.
Future Medical School ECG Activities/Research
A survey-based ECG research study was approved by NYITCOM’s Education Research Data Committee and their Institutional Review Board to evaluate medical students’ perception of ECG education and their interpretation confidence/skills. NYITCOM hopes to present the results of this study in the near future. The COVID-19 pandemic has provided a fertile ground for widespread innovation and exploration of new teaching methods in medical education. Dr. Cohen has also created at NYITCOM an ECG education team who are currently exploring a novel ECG certification process to help motivate all medical students to improve their ECG interpretation skills.
Generalizing ECG Education to Other Healthcare Workers
Lessons learned during ECG education at a medical school can also be applied to other healthcare workers. The materials and lectures may benefit healthcare trainees and those who work in an electrophysiology laboratory and/or an arrhythmia/device clinic. Virtual ECG workshops can also be opened to other healthcare training programs within and beyond the NYIT campus (nursing/physician programs). In addition, a planned ECG certification process has the potential to further the education of not only medical students, but also allied professionals who work in an EP lab and affiliated arrhythmia clinics. Finally, an improvement in ECG education for all medical personnel may play a role in providing enhanced patient care.
Conclusion
ECG education is a mainstay in medical school, but lessons learned from their education can benefit others, including electrophysiology laboratory staff and clinics. The future is evolving, and hybrid models of education, including virtual workshops, have the potential to go beyond educating just medical students.
Disclosures: The authors have no conflicts of interest to report regarding the content herein.
References
1. Salerno SM, Alguire PC, Waxman HS. Competency in interpretation of 12-lead electrocardiograms: a summary and appraisal of published evidence. Ann Intern Med. 2003;138(9):751-760.
2. Jablonover RS, Lundberg E, Zhang Y, Stagnaro-Green A. Competency in electrocardiogram interpretation among graduating medical students. Teach Learn Med. 2014;26(3):279-284.
3. Eslava D, Dhillon S, Berger J, Homel P, Bergmann S. Interpretation of electrocardiograms by first-year residents: the need for change. J Electrocardiol. 2009;42:693-697.
4. Berger JS, Eisen L, Nozad V, et al. Competency in electrocardiogram interpretation among internal medicine and emergency medicine residents. Am J Med. 2005;118(8):873-880.
5. Lee TH, Rouan GW, Weisberg MC, et al. Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room. Am J Cardiol. 1987;60:219-224.
6. Pourmand A, Tanski M, Davis S, Shokoohi H, Lucas R, Zaver F. Educational technology improves ECG interpretation of acute myocardial infarction among medical students and emergency medicine residents. West J Emerg Med. 2014;16(1)133-137.
7. Viljoen CA, Miller RS, Manning K, Burch VC. Effectiveness of blended learning versus lectures alone on ECG analysis and interpretation by medical students. BMC Med Educ. 2020;20(1):488.
8. Dung DTH. The advantages and disadvantages of virtual learning. IOSR-JRME. 2020;10(3):45-48.
9. Mahler SA, Wolcott CJ, Swoboda TK, Wang H, Arnold TC. Techniques for teaching electrocardiogram interpretation: self-directed learning is less effective than a workshop or lecture. Med Educ. 2011;45(4):347-353.
10. Nillson M, Östergren J, Fors U, et al. Does individual learning styles influence the choice to use a web-based ECG learning programme in a blended learning setting? BMC Med Educ. 2012;12:5.
11. Raupach T, Brown J, Anders S, Hasenfuss G, Harendza S. Summative assessments are more powerful drivers of student learning than resource intensive teaching formats. BMC Med. 2013;11:61.
12. Bojsen SR, Räder SBEW, Holst AG, et al. The acquisition and retention of ECG interpretation skills after a standardized web-based ECG tutorial-a randomised study. BMC Med Educ. 2015;15:36.
13. Baral R, Murphy DC, Mahmood A, Vassiliou VS. The effectiveness of a nationwide interactive ECG teaching workshop for UK medical students. J Electrocardiol. 2020;58:74-79.
