Electrocardiograms (ECGs) are consistently one of the most dreaded topics to learn in medical school. They are often described by medical students as "low-yield," a term indicating that something isn't heavily tested on medical board exams. Despite this, ECGs are used almost every day in many specialties and at least weekly in others. It is difficult to find a medical facility without access to a 12-lead ECG machine. ECGs can tell you about a patient's cardiac structure and function (including coronary arterial circulation, cardiac chamber enlargement and/or hypertrophy, congenital heart defects, etc.), and can even detect certain pulmonary and electrolyte abnormalities. Additionally, ECGs can reflect physiological changes that occur with many different medications. Clearly, they are an important resource for a clinician to have. However, we must admit that they have been a struggle for us [medical students] to learn, as well as for many of our peers. Trying to interpret the rhythm, axis and meaning of each strip has not been easy, despite our interest in the heart and cardiac pathology. This piece will consider some possibilities for demystifying the ECG at the medical student level.

At our medical school, New York Institute of Technology College of Osteopathic Medicine (NYITCOM), there are several different curricular tracks. One of them is called the Doctor-Patient Continuum and it is entirely based on problem-based learning, where all medical knowledge is acquired through the lens of prepared patient cases. Over the course of the first and second year, medical students in this curriculum see approximately one ECG per week and correlate the ECG to different medical presentations and pathologies, both cardiac and non-cardiac. In contrast, the Lecture-Discussion-based curriculum students learn ECGs through a series of four one-hour lectures, without a chance to integrate that knowledge with a clinical case. It is a well-demonstrated theory in education literature that spaced repetition is key to learning in medical education.¹ Thus, we argue that repeated exposure to ECGs in many clinical contexts over the entirety of medical education could improve interpretation skills among students.

In addition to the benefits that spaced repetition has on knowledge retention, we wonder how it can affect a student's confidence in their ability to interpret ECGs. In the Doctor-Patient Continuum curriculum, each time a student is handed a patient's ECG, they are required to state their interpretation of it to the faculty facilitator. Preliminary studies have illustrated that provider confidence is an influential factor in creating positive patient experiences.²

In the spirit of the Doctor-Patient Continuum curriculum, we propose that all medical students should be exposed to interpreting ECGs throughout their medical education. There are several ways this could be accomplished. Here at NYITCOM, students in the Lecture-Discussion-based program attend small group learning once a week throughout both years of the preclinical medical school curriculum. In these weekly sessions, students review a patient case related to the system they are currently learning. We propose that in each of these sessions, students are presented with an ECG of the patient in their clinical vignette. By repeated exposure to ECGs, medical students will become more confident in their abilities to successfully interpret ECGs.

We began conceptualizing this new model at the beginning of 2021. Working with Todd J. Cohen, MD, FACC, chief of cardiology and director of Medical Device Innovation at NYITCOM, we advocated for more ECG education at our school. To our excitement, our school decided to implement the educational model of including one ECG with each patient case seen weekly in small group learning sessions. We are fortunate that this change is being implemented and we look forward to seeing the impact that it has on ECG education in our school. We hope and encourage other medical schools to look to similar small group-based ECG education, centering around spaced repetition.

The utility of ECGs in all aspects of medicine cannot be overstated. By using spaced repetition learning models, we believe that medical students will rapidly gain confidence and competence in interpreting and applying ECGs in a clinical context.

References:

1. Raupach T, Brown J, Anders S, et al. Summative assessments are more powerful drivers of student learning than resource intensive teaching formats. BMC Medicine 2013;11,61.
2. Owens, Katie & Keller, Stephanie. Exploring workforce confidence and patient experiences: A quantitative analysis. Patient Experience Journal 2018;5(97)105.

This article was authored by Sarah J. Muder, BA, DO Candidate, NYITCOM Class of 2023; Chiya Abramowitz, BA, MS, DO/MBA Candidate, NYITCOM Class of 2024 and Denis Malkov, MD, CCT, CCDS, DO/MBA Candidate, NYITCOM Class of 2024.