Web-based ECG education : utility and usage in undergraduate medical education

Investigating the heart with an electrocardiogram (ECG) is an important, frequent and noninvasive investigation. Failure to correctly interpret the ECG may harm the patient. Learning to interpret ECGs is difficult for many medical students. Students and teachers have asked for more training, but this is difficult to provide in traditional educational settings. A web-based learning resource could be useful and this thesis aimed to explore the utility and usage of a web-based ECG resource for medical students in a blended-learning setting.

Methods and result: Study I evaluated a web-based ECG learning resource at the clinical internal medicine course in the medical programme. In a non-randomised study with an interventional arm and a control arm 62% of the students in the intervention group used the resource. The users ranked the ECG learning resource as a useful instrument to learn ECG. An optional ECG diagnostic test was performed with students from both the interventional and the control group. The mean result was better in the interventional than in the control group (p = 0.03). The intervention group improved learning with an effect size of 0.65 (Cohen's da). Study II was a case-control study that investigated whether students´ learning styles influenced the decision to use or not to use the web-based ECG learning resource during a pre-clinical course in diagnostic methods. Fifty-five students (59%) were users of the web-based learning resource. We found no evidence to support that learning styles influenced the students´ choices to use the web-based ECG-learning resource. Study III further explored why medical students chose to use or not to use the web-based resource in a blended-learning setting. In a mixed-methods study we explored medical students' rationales for this choice. The web-based ECG learning resource contributed to student learning based on principles of self-regulated learning, in which students made their decisions based on a multitude of factors. These factors included experiences during clinical rotations, previous study experiences and strategies for regulating learning. Study IV investigated ECG-interpretation skills of final-year medical students. Additional assessments included attitudes toward ECG, individual skills and different methods of learning. To our knowledge, the students did not have access to the web-based resource used in the other studies of this thesis. The median test result (IQR) was 50.8% (37.6–60.0%). There was a gender difference; male students had higher average scores. Thirty-nine percent of the students stated that they were unsure of ECG interpretation. Student estimations of their ECG-interpretation skills correlated with diagnostic test scores (r = 0.38, p < 0.001) but with a gender difference: females r = 0.48, p < 0.001 and males r = 0.035, p = 0.82.

Conclusions: Adding a web-based ECG learning resource in a blended-learning context seems to be more effective than just using traditional teaching methods. There are few barriers to effective use of a web-based ECG learning resource in a blended-learning setting. However, not all students need supporting learning resources. A supplementary web-based ECG learning resource contributes to student learning based on principles of self-regulated learning in which students make their decisions based on a multitude of factors. Graduate medical students recognise the importance of ECG skills both in their present situation and in their future role as physicians. Despite this, more than one third of the students stated that they were unsure of ECG interpretation. The students’ test results confirmed a lack of skills, with poor scores for ECG interpretation even in cases with life-threatening diseases. What should be explored is how useful a web-based learning resource can be and how long-term use could enhance long-term skills. Further research is needed about how to secure enough ECG-knowledge among medical students reaching their final examination.

List of scientific papers

I. Mikael Nilsson, Gunilla Bolinder, Claes Held, Bo-Lennart Johansson, Uno Fors and Jan Östergren. Evaluation of a web-based ECG-interpretation programme for undergraduate medical students. BMC Medical Education. 2008, 8:25.
https://doi.org/10.1186/1472-6920-8-25

II. Mikael Nilsson, Jan Östergren, Uno Fors, Anette Rickenlund, Lennart Jorfeldt, Kenneth Caidahl, Gunilla Bolinder. Does individual learning styles influence the choice to use a web-based ECG learning programme in a blende d learning setting? BMC Medical Education. 2012,12(1):5.
https://doi.org/10.1186/1472-6920-12-5

III. Mikael Nilsson, Uno Fors, Jan Östergren, Gunilla Bolinder, Samuel Edelbring. Why medical students choose to use or not to use a web-based electrocardiogram learning resource: mixed methods study. JMIR Med Educ. 2019;5(2):e12791.
https://doi.org/10.2196/12791

IV. Mikael Nilsson, Samuel Edelbring, Uno Fors, Gunilla Bolinder, Jan Östergren. Graduating medical students lack sufficient skills despite recognizing the importance of electrocardiogram interpretation. [Submitted]