The ECG-training programme
Clinical ECG interpretation requires basic knowledge from several fields of medicine, such as anatomy, physiology and clinical pathophysiology. A web-based ECG interpretation programme "EKGtolkning.com" was selected for this study. EKGtolkning.com has previously been utilized in the continuing medical education (CME) of clinically active physicians in an ECG interpretation course at Karolinska Institutet The program is also used in an online course for nurses. The programme was modified with a pre-test module to suit the needs of undergraduate medical education in terms of test situations. The programme was designed to serve both as a complement to the standard ECG education, or to be used as "stand-alone" tool for self-regulated learning.
The web-based system contains all information that medical students at Karolinska Institutet should need during a basic ECG-interpretation course [3, 7]. The content is divided into separated parts: Clinical introduction, The ECG in detail, the pathological ECG and clinical ECG cases.
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Clinical introduction gives a basic understanding of the electric activity of the heart and how this is registered using electrocardiography. It also includes clinical symptoms, anatomy and physiology to give a basic understanding of the placement and orientation of the heart within the chest and its relation to the ECG-electrodes. This section also covers the anatomy and function of the cardiac conduction system as well as the electrophysiological properties of the heart.
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The ECG in detail covers the basic principles of ECG, where the ECG registration is discussed in detail. A summary with conclusions and a thorough review of the ECG-interpretation checklist is included.
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The section with pathological ECG:s, covers common pathological ECG anomalies. 25 conditions are presented and explained.
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The clinical ECG cases consist of 70 specially selected ECG:s, together with short descriptions of the clinical situations in which the ECG-tracings were recorded. They exemplify a number of typical cases, in which ECG interpretation is important.
The programme was designed in accordance with parts of several learning theories, among others Kolb's Experiential Learning [13]. The theory includes four elements: concrete experience, observation and reflection, the formation of abstract concepts and testing in new situations.
The Programme uses three pedagogical and technical solutions to implement the different parts of the course:
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1.
The core learning objects (Fig 1) constitute the theoretical backbone of the course. The core learning objects is made by text, animations and illustrations.
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2.
The interactive ECG interpretation module (Fig 2) allows students to interpret authentic ECG registrations using a number of tools and utilities. Clinical history and information on the actual ECG is also presented. The module presents an opportunity to practice, apply and develop interpretation skills based on the assumption that the students interpretation combined with the possibility to compare with an interpretation made by an expert will facilitate the gain of knowledge. The module thus tries to mimic the clinical reality in order to optimize ECG understanding and interpretation [14, 15].
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The linear test system (Fig 3) is a tool for running and tracking tests. The questions are defined in an external file and interpreted by the system. The questions are constructed in order to achieve maximal learning levels according to Blooms Taxonomy of Educational Objectives [16].
Test setting
Medical students from the sixth semester at the Karolinska Institutet who attended the internal medicine course at Karolinska University Hospital (12 males, 20 females, mean age 27 years) were offered to use the programme from the start of their course as an adjunct to the conventional training in ECG interpretation. The ECG system was introduced during a 40 minute lecture and students were encouraged to use the programme for training on a voluntary basis. The students was informed about the study and gave consent to it as well as to publication. It was possible to use the system at any time during the course through any Internet connected computer. Logged on, the students had access to all material in the program without demands of sequence or test of skills.
User activity was automatically logged. An evaluation of attitudes towards web-based ECG-learning in general and the utility of the specific programme was obtained after 2 months. This was performed as part of an individual semi-structured interview with all students during the course of an individual personal development dialogue, by one of the authors (JÖ) asking about the students opinion of the a) general utility of web based ECG as a learning tool and b) the quality of the specific programme used. The opinions were ranked on a 5-graded scale.
A diagnostic test was performed at the end of the 5-month course to assess the possible effect on skills in ECG interpretation/reading. Students from the corresponding sixth semester course, at another teaching hospital in the Stockholm area (14 males, 16 females, mean age 26 years), without access to the web-based programme served as a control group. However, the latter group of students received 3.5 days of extra training in clinical physiology, including interpretation of ECG. In addition both the intervention group and the control group had received a 15 hour long course in ECG-interpretation during the 5th semester.
Grading of the individual diagnostic test results was performed without the examiner knowing the identity of the subjects or to which course they belonged. Results of the test were compared between the two courses by Students T-test (two-sided).