Proposed In-Training Electrocardiogram Interpretation Competencies for Undergraduate and Postgraduate Trainees
Despite its importance in everyday clinical practice, the ability of physicians to interpret electrocardiograms (ECGs) is highly variable. ECG patterns are often misdiagnosed, and electrocardiographic emergencies are frequently missed, leading to adverse patient outcomes. Currently, many medical education programs lack an organized curriculum and competency assessment to ensure trainees master this essential skill. ECG patterns that were previously mentioned in literature were organized into groups from A to D based on their clinical importance and distributed among levels of training. Incremental versions of this organization were circulated among members of the International Society of Electrocardiology and the International Society of Holter and Noninvasive Electrocardiology until complete consensus was reached. We present reasonably attainable ECG interpretation competencies for undergraduate and postgraduate trainees. Previous literature suggests that methods of teaching ECG interpretation are less important and can be selected based on the available resources of each education program and student preference. The evidence clearly favors summative trainee evaluation methods, which would facilitate learning and ensure that appropriate competencies are acquired. Resources should be allocated to ensure that every trainee reaches their training milestones and should ensure that no electrocardiographic emergency (class A condition) is ever missed. We hope that these guidelines will inform medical education programs and encourage them to allocate sufficient resources and develop organized curricula. Assessments must be in place to ensure trainees acquire the level-appropriate ECG interpretation skills that are required for safe clinical practice.
© 2018 Society of Hospital Medicine
The 12-lead electrocardiogram (ECG) remains one of the most widely used and readily available diagnostic tests in modern medicine.1 Reflecting the electrical behavior of the heart, this point-of-care diagnostic test is used in almost every area of medicine for diagnosis, prognostication, and selection of appropriate treatment. The ECG is sometimes the only and most efficient way of detecting life-threatening conditions, thus allowing a timely delivery of emergency care.2 However, the practical power of the 12-lead ECG relies on the ability of the clinician to interpret this test correctly.
For decades, ECG interpretation has been a core component of undergraduate and postgraduate medical training.3-5 Unfortunately, numerous studies have demonstrated alarming rates of inaccuracy and variability in interpreting ECGs among trainees at all levels of education.4,6,7 Senior medical students have been repeatedly shown to miss 26% to 62% of acute myocardial infarctions (MI).6,8-10 Another recent study involving internal medicine residents demonstrated that only half of the straightforward common ECGs were interpreted correctly, while 26% of trainees missed an acute MI and 56% missed ventricular tachycardia (VT).11 Even cardiology subspecialty fellows demonstrated poor performance, missing up to 26% of ST-elevation MIs on ECGs that had multiple findings.12 Inaccurate interpretations of ECGs can lead to inappropriate management decisions, adverse patient outcomes, unnecessary additional testing, and even preventable deaths.4,13-15
Several guidelines have emphasized the importance of teaching trainees 12-lead ECG interpretation and have recognized the value of assessments in ensuring that learners acquire the necessary competencies.16-19 Similarly, there have been many calls for more rigorous and structured curricula for ECG interpretation throughout undergraduate and postgraduate medical education.11,16 However, we still lack a thoughtful guideline outlining the specific competencies that medical trainees should attain. This includes medical students, nurses working in hospital and in out-of-hospital settings, and residents of different specialties, including emergency medicine, cardiology, and electrophysiology (EP) fellows.
Setting goals and objectives for target learners is recognized to be the initial step and a core prerequisite for effective curriculum development.20 In this publication, we summarize the objectives from previously published trainee assessments and propose reasonably attainable ECG interpretation competencies for both graduating medical students and residents at the end of their postgraduate training. This document is being endorsed by researchers and educators of 2 international societies dedicated to the study of electrical heart diseases: the International Society of Electrocardiology (ISE) and the International Society of Holter and Noninvasive Electrocardiology (ISHNE).
METHODS
Current Competencies in Literature
We performed a systematic search to identify ECG competencies that are currently mentioned in the literature. Information was retrieved from MEDLINE (1946-2016) and EMBASE (1947-2016) by using the following MeSH terms: electrocardiogram, electrocardiography, electrocardiogram interpretation, electrocardiogram competency, medical school, medical student, undergraduate medicine, undergraduate medical education, residency education, internship, and residency. Our search was limited to English-language articles that studied physician trainees. The references of the full-length articles were examined for additional citations. The search revealed a total of 65 publications involving medical students and 120 publications involving residents. Abstracts of publications were then assessed for relevance, and the methods of the remaining articles were scrutinized for references to specific ECG interpretation objectives. This strategy narrowed the search to 9 and 14 articles involving medical students and residents, respectively. Studies were not graded for quality because the purpose of the search was to identify the specific ECG competencies that authors expected trainees to obtain. Almost all the articles proposed teaching tools and specific objectives that were defined by the investigators arbitrarily and assessed the trainee’s ability to interpret ECGs (summarized in supplementary Table).
