Medical students are inherently competitive, often motivated by a desire to excel and to achieve more than their peers(1). This sense of competition has existed within them before medical school; from exams to applications, these students have had to outscore their competitors just to be given the opportunity to study medicine.  This continues into medical school with some students even believing that competition, as opposed to co-operation, is the defining characteristic of medicine(2).

Throughout the course of medical school, institutions run into various problems with teaching and maintaining student attendance and performance.  Students have a tendency to become de-motivated as their medical degree progresses and can become prone to apathy during lectures(3).  This has been attributed to the repetitive nature of medical learning and the heavy workload and subsequent burnout attributed to a medical degree(4).  Absenteeism is also a problem(5), with teachers and institutions constantly having to employ new strategies and programs to ensure continued student motivation and participation.

There is clearly a need for improvements in the way knowledge and understanding are imparted to learners(6,7). To achieve our aim, we looked at the teaching of electrocardiograms as enough is still not known about how best to teach ECG interpretation to medical students.  Graduating medical students are expected to possess basic ECG interpretation skills but clinical tutors are yet to agree on the best method for teaching these skills.  Some studies have shown that students taught using lecture and workshop based formats scored higher on tests than students who used self-directed learning (8) whilst others have concluded that knowledge assessment was significantly better amongst students receiving self-instruction modules(9).  Other studies show that the ideal method of attaining and evaluating ECG interpretation skills is lacking and warrant further investigation(10,11).  This research proposes that whatever method is used, introducing competition would enhance learning and performance. 

This study hypothesises that utilizing a medical student’s natural competitive instincts might be one method to enhance ECG learning. It focuses on using an andragogical approach as opposed to a pedagogical approach to instilling knowledge and the development of skills.  It works from the assumption that all medical students are adults and, even though many may not ever have had a break from formalised education, all are competitive by nature and therefore possess a degree of internal motivation which can be harnessed to achieve an educational outcome(12). Certainly, many medical schools offer competitions and prizes to help draw interest and participation.  In fact, some studies have shown improvements in results and participation by instilling an element of competition to their teaching(13,14). In other fields, including business and sport,  competition and competitiveness have been utilized to enhance learning and performance(15,16,17).

This study uses and tests competition in ECG teaching as a starting point to further exploration of competition as a driver in medical education more widely.

Methods

A structured ECG teaching session was carried out on 1st year students at a major London teaching hospital. The students had little or no previous ECG teaching. The students were split into two groups and the same lecture was delivered to the two groups with a subsequent examination.  A prize was offered to Group 1 for the highest scorer, but not to Group 2. Six ECG topics, consisting of 6 items each, were evaluated: normal ECG, STEMI, NSTEMI, hyperkaelemia, AF and WPW syndrome.

124 students (49% male) participated (69 students in Group 1, 55 students in Group 2).  Group 1 (19.58 (6.54)) scored significantly higher in total than Group 2 (17.02 (6.19), p<0.05; figure 1), with greater scores on normal ECG (3.8(1.8)vs(2.7(1.9),p<0.0001), STEMI (3.4(1.4)vs(2.7(1.5),p<0.0001), NSTEMI (3.3(1.7)vs(2.7(1.6), p<0.001), AF (3.6(1.4) vs WPW 3.5(1.5), non-significant) and hyperkaelemia (3.4(1.8)vs3.4(1.4), non-significant).