We used the Kern Six-Step Approach to Curriculum Development [14]. (1) Problem identification began with a review of ECG education literature and the current local ECG curriculum, which revealed a lack of standardization in teaching and unclear objectives based on learners’ level of training. Although these problems were seen across all levels of training (undergraduate, post-graduate, and in-practice training), the goals of the program targeted undergraduate and junior Emergency Medicine post-graduate medical learners. The program’s goals and objectives and a systematic approach to ECG interpretation were developed based on feedback obtained from the second step of the Kern-Approach—Targeted Needs Assessment.

(2) Targeted needs assessment then surveyed medical students and EM residents at our institution, the University of Toronto, to understand their current gaps in their ECG learning and preference in the mode of delivery. This took place in two phases; the first took place 3 months prior to the workshop, which helped prepare the general material. The local medical school class was polled to gauge their interest in an ECG workshop and suggestions for material. The second was completed 1 week before the workshop to poll the participants for their feedback. Themes that emerged from these surveys included the need for more dedicated teaching using a systematic approach to ECG interpretation, developing an approach to identify common and emergent diagnoses, and learning how ECGs can be used in the workup of common emergency presentations including syncope, ischemia, and arrhythmias.

Then, all participants were sent and responded to pre-workshop surveys (13 residents and 126 medical students). All residents (100%) and a majority of medical students (88%) believe that interpreting ECGs is an essential skill for physicians. But a majority of residents and medical students indicated they had received less than 15 h of dedicated ECG training in their undergraduate medical training (70% and 87% respectively); a majority felt this was inadequate (85% and 79%, respectively); and a majority did not feel confident interpreting ECGs (69% and 80%, respectively). Further, survey respondents also indicated that interpreting ECGs in a clinical setting makes them feel anxious (61% and 83%, respectively). Qualitative survey responses requested a step-by-step approach to ECGs and pearls to guide clinical decision-making. Common themes that emerged from both residents and medical students is the need for iterative application of an ECG approach to consolidate their knowledge and build an understanding of ECG interpretation based on pathophysiology and clinical relevance. There was also an emphasis on interactive, small-group learning over didactic lectures or self-directed modules. Residents indicated that they hoped to gain competency in ECG interpretation through teaching and gain confidence in teaching complex concepts to others using a simplified systematic approach.

These informed the program’s (3) goals and objectives. Broad goals included learning a systematic approach to ECG interpretation, and understanding how this can help guide emergency management. Specific objectives included learning the HEARTS approach to ECG interpretation, applying this to 5 common emergency presentations, and specific objectives for each. First, 20 ECGs were selected from a consensus of Canadian EM residency program directors for what EM residents need to know [2]. To reinforce clinical relevance, ECGs were then categorized into five frequently encountered clinical presentations in the ED (i.e., palpitations, weakness, syncope, shortness of breath, and chest pain). Then ECGs were interpreted systematically through the HEARTS approach and linked with clinical management—including pitfalls and pearls for each category of cases. Table 1 provides an overview of the workshop materials, including the specific objectives for each category of presentations.

(4) Educational strategy included content based on the HEARTS approach, and methods including flipped classrooms and learning through teaching [15, 16]. The HEARTS approach begins with an analysis of the Heart rate and rhythm, including how to identify sinus rhythm and diagnose arrhythmias. Second, Electrical conduction assesses the intervals (PR, QRS, QT), and identifies various abnormalities (e.g., WPW, AV blocks, bundle branch blocks, long QT). Third, the limb leads are used to determine the Axis and differentiate different causes of right, left, or extreme axis deviation. Fourth, the precordial leads are used to determine R-wave progression and differentiate different causes of early progression (e.g., RVH, posterior MI, left-sided WPW) or late progression (e.g., anterior infarct). Fourth, the limb and precordial leads are used to assess Tall/small voltages and to differentiate between different causes of tall (e.g., LVH, BER), or small voltages (e.g., pericardial effusion, COPD). Finally, ST/T analysis is deliberately put at the end of interpretation, both to reinforce that these changes can be secondary to abnormalities in rate/conduction/voltage and to help differentiate between secondary and primary changes. This is followed by a summary that consolidates the findings and then puts it in the context of the patient to guide management.

This content was delivered through a flipped classroom method including pre-workshop didactic material, and small group workshop based on near-peer teaching. Pre-workshop preparation material was provided to medical students and EM residents that introduced them to the HEARTS approach. A 15-page PDF was emailed to all participants to read in advance of the workshop. This covered the basics of ECGs including the foundations of cardiac electrophysiology and cardiac anatomy, pictorial correlations with pathophysiology, ECG lead placements, ECG intervals and segments, and then a description and rationale of the HEARTS approach.

Junior EM residents (first and second year) were recruited to facilitate the workshop, under the supervision of an EM physician. EM residents used a pre-workshop manual and teaching slides to learn the approach and to prepare to facilitate the workshop. The teaching slides included a summary of the learning point for each common presentation, and then each of the 20 ECGs was broken down into an individual slide for each component of Heart rate, Electrical conduction, Axis, R-wave progression, Tall/small voltages, and ST/T changes. This was followed by a slide integrating the findings and linking them to emergency management. Residents engaged in a one-hour preparatory session, 1 week prior to the workshop for an overview of the materials and answer questions. It was emphasized that while there would be an EM physician available to oversee the teaching and answer any questions, the residents themselves would be responsible for learning the material to the point of being able to teach it to students—so that residents would learn through the process of preparing and delivering educational material.

The workshop began with an introductory first session provided by the EM physician, which further didactically reinforced the pre-workshop material. This provided all learners the opportunity to ask questions and understand the approach prior to its iterative application to clinical cases.

The remainder of the workshop constituted small learner groups, each facilitated by a resident. Within the groups, students were asked to interpret the ECG in a step-by-step fashion based on the HEARTS approach. Students would take turns going through each component of the ECG: one student would interpret Heart rate/rhythm, then the next would interpret Electrical conduction, etc. Residents then used slides to highlight both normal and abnormal findings, linked to underlying pathophysiology and clinical relevance. Findings were then amalgamated onto a final slide that allowed students to highlight significant findings and a summary interpretation, which was then linked to clinical management (example shown in Fig. 1) and a discussion of pitfalls and pearls. This process allowed for near-peer teaching and benefited both the facilitator and the learner by learning, applying, and consolidating a systematic approach to ECG interpretation using a repetitive cycle to reinforce and consolidate the HEARTS approach. In other words, the vast majority of the workshop involved residents teaching medical students, learning through the process of teaching. The role of the supervising EM physician was to prepare the pre-workshop material, review all the workshop slides with residents in advance to ensure they were able to teach the material and circulate between the small groups during the workshop to address any questions from medical students for which the residents required further clarification.

Example of the HEARTS approach and its application on an ECG

(5) Implementation included 1 hour pre-workshop reading and a 5-h virtual workshop with supervised small group teaching with an average of 5:1 student-to-facilitator ratio. The workshop was piloted with 6 junior EM residents and 58 medical students. After evaluation and feedback, it was repeated and expanded to nine junior EM residents and 68 medical students from four medical schools, resulting in a total of 15 residents and 126 medical students (16 s-year, 91 third-year, and 19 fourth-year students).