Bridging the gap: using an asynchronous e-Learning module to improve internal medicine residents’ confidence and preparedness in ambulatory blood pressure monitoring interpretation

Abstract

Background

Ambulatory blood pressure monitoring (ABPM) is considered a reference standard for diagnosing hypertension and is recommended for out-of-office blood pressure assessment, yet internal medicine residents receive limited training in its interpretation. We conducted a needs assessment to identify gaps in hypertension and ABPM education and developed an asynchronous e-learning module to address these deficiencies. We then evaluated its impact on residents’ self-reported confidence and preparedness in outpatient hypertension management.

Methods

We conducted a single-center quality improvement study among internal medicine residents (PGY1-4) at the University of Toronto between July 2024 and January 2026. A baseline needs assessment evaluated prior exposure to ABPM, confidence in interpretation, and preparedness to diagnose hypertension. An e-learning module was developed, consisting of a structured “Five Steps of ABPM Interpretation” framework and case-based learning. A post-intervention survey assessed self-reported confidence, preparedness, and educational value. Descriptive statistics were used to summarize outcomes. Between-group comparisons of categorical outcomes were performed using chi-square tests.

Results

Sixty-two residents completed the baseline survey, and 26 completed the module and post-intervention survey [1]. At baseline, 56.5% (35/62) reported no prior exposure to ABPM interpretation. Only 22.6% (14/62) felt comfortable interpreting ABPM reports, and 32.3% (20/62) felt prepared to diagnose outpatient hypertension. Following the intervention, 84.6% (22/26) of residents reported feeling comfortable or very comfortable interpreting ABPM, and 92.3% (24/26) reported feeling prepared or very prepared to diagnose hypertension. Learner satisfaction was high, with over 90% of participants reporting that the module was educationally valuable, easy to use, and effective.

Conclusions

An asynchronous, case-based e-learning module was feasible, well-received, and associated with higher self-reported confidence and preparedness in ABPM interpretation among internal medicine residents. The observational nature and potential for both response and selection bias limits generalizability of the study.

Background

Hypertension remains one of the most common conditions managed in outpatient internal medicine. Hypertension Canada emphasizes out-of-office blood pressure measurements, including ambulatory blood pressure monitoring (ABPM), for the diagnosis and management of hypertension [2–4], reflecting the increasing complexity of blood pressure assessment beyond clinical measurements [5]. The Royal College of Physicians and Surgeons of Canada similarly recognizes ABPM-based hypertension care as a core competency in training [6]. Despite this, the extent of resident training in outpatient hypertension care remains unclear, raising concern that trainees may lack the necessary skills to accurately diagnose and manage hypertension, potentially leading to suboptimal patient outcomes. Within Canada, internal medicine training is primarily based in the acute care setting, while most patients with hypertension are diagnosed and managed as outpatients. This limits residents’ exposure to diagnosis of new hypertension. In addition, there is a general lack of access to 24-hour ABPMs (either requiring payment by patients or no availability) which also limits residents’ exposure to interpretation of 24-hour ABPMs. We conducted a needs assessment to explore gaps in hypertension education and inform development of an asynchronous e-learning module focused on ABPM interpretation. We then evaluated its impact on residents’ self-reported comfort, preparedness, and perceptions of the digital interface.

Methods

This study was conducted among internal medicine residents (PGY1–4) at the University of Toronto between July 2024 and January 2026. All eligible residents were invited to voluntarily participate. The pre-intervention needs assessment (2024–2025 cohort, n = 267) and post-intervention evaluation (2025–2026 cohort, n = 272) were conducted as separate survey samples and created de novo for this study. Surveys were reviewed by two content experts in hypertension and medical education for content validity and were piloted and updated accordingly for question clarity prior to distribution. Three survey reminders were sent out for each survey to encourage participation. Participation in the post-intervention survey was voluntary and not linked to individual baseline responses. Informed consent was obtained prior to survey completion [1, 7]. Participants received a $20 gift card. A needs assessment survey assessed postgraduate training level, prior exposure to ABPM interpretation, and self-reported comfort interpreting ABPM and preparedness to diagnose outpatient hypertension [7]. Based on the results, an asynchronous ABPM e-learning module was developed using the Articulate platform. The module consisted of two components: (1) “Five Steps of ABPM Interpretation” and (2) an interactive case-based section including five clinical cases with real ABPM reports. The “Five Steps” detailed an overview of ABPM interpretation including: (1) confirming demographics (2), assessing quality of ABPM report (3), interpreting mean daytime and nighttime blood pressure values (4), evaluating nocturnal dipping, and (5) applying treatment considerations. Each overview step was embedded with references to standard ABPM reports with direct visual cues on where to find information within the report and how to assess the graphs with important caveats (Fig. 1).

Fig. 1.

Structure and interface of the ABPM e-module. A Overview of the “Five Steps of ABPM Interpretation” framework. B Example of an interactive case with embedded knowledge checks and immediate formative feedback

Following this overview, residents progressed through three to five interactive ABPM cases with embedded knowledge checks aligned with each step. Immediate formative feedback was provided, including interactive explanations for both correct and incorrect responses to reinforce key learning points. The module was designed to be completed in approximately 30–60 min depending on the number of cases completed.

Content was peer-reviewed by two internal medicine faculty. The post-intervention survey assessed self-reported comfort and preparedness, exposure to ABPM cases following module completion, and perceptions of value and usability [1]. Consistent with the study objective of assessing self-reported confidence and preparedness, rather than objective knowledge acquisition, no objective knowledge testing was performed. No personally identifying information was collected, and all data were stored securely. Descriptive statistics were used to summarize participant characteristics, prior ABPM exposure, and self-reported outcomes. Categorical variables were summarized using frequencies and percentages. Between-group comparisons of categorical outcomes were performed using chi-square tests, given use of independent pre-and post-intervention samples. A p-value < 0.05 was considered statistically significant. The project fell within a quality improvement framework and was deemed exempt from formal research ethics board (REB) submission.

Results

Sixty-two residents completed the needs assessment, and 26 residents completed the e-learning module and post-intervention survey [1] (Table 1). These represent two independent, unmatched samples, and it is not known whether individual participants overlapped between cohorts. At baseline, 56.5% (35/62) of residents reported having no exposure to ABPM interpretation during residency training. Only 22.6% (14/62) reported feeling comfortable or very comfortable interpreting ABPM reports, and 32.3% (20/62) reported feeling prepared or very prepared to diagnose hypertension in the outpatient setting. Compared with the pre-intervention cohort, a significantly higher proportion of residents in the post-intervention cohort reported feeling comfortable or very comfortable interpreting ABPM reports (84.6% (22/26) vs. 22.6% (14/62), χ² = 29.16, p < 0.001). Similarly, a significantly greater proportion reported feeling prepared or very prepared to diagnose hypertension in the outpatient setting (92.3% (24/26) vs. 32.3% (20/62), χ² = 26.42, p < 0.001). After module completion, 42.3% reported interpreting greater than 1 ABPM in a clinical environment, and 96.1% reported completing 3 or more ABPMs via simulated environment. Most found the module educationally valuable, with 92.1% agreeing or strongly agreeing that the asynchronous digital format was effective. Additionally, 92.3% agreed or strongly agreed that the platform was easy to use and facilitated learning.

Table 1.

Resident participation and distribution

Characteristic	Pre-intervention (needs assessment)	Post intervention (e-learning and survey)
Number of residents (N)	62	26
PGY1 (%)	25.8	30.8
PGY2 (%)	35.3	30.8
PGY3 (%)	30.6	34.6
PGY4 (%)	8.1	3.8

Discussion

This study highlights an educational gap in hypertension diagnosis and ABPM interpretation. Residents in the pre-intervention cohort reported limited exposure and low confidence in ABPM interpretation, underscoring a disconnect between guideline-recommended practice and current training. Implementation of an asynchronous, case-based e-learning module was associated with higher self-reported comfort with ABPM interpretation and perceived preparedness to diagnose outpatient hypertension, with statistically significant differences between unmatched pre-and post-intervention cohorts. The design of the module aligns with principles of adult learning theory, emphasizing self-directed, problem-centered learning and immediate application of knowledge [8]. Following module completion, residents reported greater confidence and readiness to use ABPMs clinically, consistent with prior postgraduate medical education literature demonstrating that asynchronous digital learning interventions can enhance learner confidence, perceived competence, and accessibility of education in time-constrained training environments [9, 10]. From a medical education perspective, the novelty of this intervention lies in the integration of a structured, stepwise approach to ABPM interpretation within a case-based, asynchronous format. High learner satisfaction supports the implementation of asynchronous digital education in outpatient rotations, with most residents endorsing the platform’s usability and educational value. This aligns with evidence supporting technology-enhanced, applied learning strategies in residency education [11, 12]. Beyond medical education, emerging digital health technologies such as artificial intelligence-enabled tools and wearable devices are increasingly being explored to support hypertension detection and control in clinical practice [13]. This model offers a scalable and resource-efficient strategy to supplement didactic teaching, supports competency-based education through deliberate exposure to ABPMs, and may be adaptable to other outpatient internal medicine topics with limited exposure. Notably, the module’s scalability is enhanced by its interactive design, which allows learners to track their progress, receive real-time tailored feedback, and interact with downloadable ABPM reports across a range of clinical scenarios – enabling standardized, yet flexible learning without additional faculty input.

This study has several limitations. As a quality improvement initiative, it was not designed to establish causality given the lack of randomization, a control group, and the use of unmatched pre-and post-intervention cohorts. Outcomes relied on self-reported comfort and preparedness rather than objective knowledge assessment or observed performance and therefore may reflect perceived rather than actual competence. Additionally, improvements may have been influenced by concurrent clinical exposure to outpatient internal medicine during the study period, rather than the intervention alone. Although statistically significant differences were observed using chi-square testing, these findings should be interpreted as associative rather than causal, particularly given potential sampling variation between unmatched cohorts. The single-institution design and small post-intervention sample limits generalizability. In addition, lower response rates in the post-intervention group, likely related to the time intensive nature of the module, introduces the potential for selection bias, with more motivated learners potentially overrepresented. It is difficult to therefore generalize this study to a more widespread acceptance and uptake of a voluntary e-module for educational purposes within a larger residency cohort. Response bias may also have impacted the validity of the results. We believe the standard asynchronous format suggests potential for adaptation across residency programs with varying curricular structures, however future studies with larger cohorts incorporating objective knowledge assessment and longer term follow up to validate these findings.

Conclusion

In conclusion, this asynchronous e-learning curriculum was feasible, well received, and associated with higher resident confidence and perceived preparedness for outpatient hypertension diagnosis using ABPMs. However, as outcomes were limited to self-reported measures, the impact on objective knowledge and clinical performance remains uncertain. Similar digital curricula may help modernize outpatient training and address persistent education gaps.

Abbreviations

ABPM

Indicates ambulatory blood pressure monitoring

PGY1

Post graduate year one

PGY4

Indicates postgraduate year four

REB

Indicates research ethics board

Authors’ contributions

Maya Stein conceptualized and designed the study, conducted data collection and analysis, and drafted the manuscript. Cameron Taheri contributed to study design and data collection. Thomas E. MacMillan contributed to study design and critical revision of the manuscript. Alison Lai contributed to study design, data interpretation, and critical revision of the manuscript. All authors approved the final manuscript.

Funding

No funding was received for this work.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This project is a quality improvement study which does not need ethics review from the University of Toronto Research Ethics Board. An exemption has been provided by the Research Ethics Board (Contact name: Daniel Gyewe, Research Ethics Manager, University of Toronto). Informed consent was obtained from all participants prior to survey completion. This research study was performed in accordance with relevant guidelines and regulations.

Consent for publication

All authors provide consent for publication.

Competing interests

The authors declare no competing interests.