Electrocardiogram Interpretation Skills Research Articles

New ideas for teaching electrocardiogram interpretation and improving classroom teaching content.

BackgroundInterpreting an electrocardiogram (ECG) is not only one of the most important parts of diagnostics but also one of the most difficult areas to teach. Owing to the abstract nature of the basic theoretical knowledge of the ECG, its scattered characteristics, and tedious and difficult-to-remember subject matter, teaching how to interpret ECGs is as difficult for teachers to teach as it is for students to learn. In order to enable medical students to master basic knowledge of ECG interpretation skills in a limited teaching time, we modified the content used for traditional ECG teaching and now propose a new ECG teaching method called the “graphics-sequence memory method.”MethodsA prospective randomized controlled study was designed to measure the actual effectiveness of ECG learning by students. Two hundred students were randomly placed under a traditional teaching group and an innovative teaching group, with 100 participants in each group. The teachers in the traditional teaching group utilized the traditional teaching outline, whereas the teachers in the innovative teaching group received training in line with the proposed teaching method and syllabus. All the students took an examination in the final semester by analyzing 20 ECGs from real clinical cases and submitted their ECG reports.ResultsThe average ECG reading time was 32 minutes for the traditional teaching group and 18 minutes for the innovative teaching group. The average ECG accuracy results were 43% for the traditional teaching group and 77% for the innovative teaching group.ConclusionLearning to accurately interpret ECGs is an important skill in the cardiac discipline, but the ECG’s mechanisms are intricate and the content is scattered. Textbooks tend to make the students feel confused owing to the restrictions of the length and the format of the syllabi, apart from many other limitations. The graphics-sequence memory method was found to be a useful method for ECG teaching.

Electrocardiogram interpretation skills among ambulance nurses

To describe ambulance nurses' practical electrocardiogram (ECG) interpretation skills and to measure the correlation between these skills and factors that may impact on the level of knowledge. This study was conducted using a prospective quantitative survey with questionnaires and a knowledge test. A convenience sample collection was conducted among ambulance nurses in three different districts in western Sweden. The knowledge test consisted of nine different ECGs. The score of the ECG test were correlated against the questions in the questionnaire regarding both general ECG interpretation skill and ability to identify acute myocardial infarction using Mann-Whitney U test, Kruskal-Wallis test and Spearman's rank correlation. On average, the respondents had 54% correct answers on the test and identified 46% of the ECGs indicating acute myocardial infarction. The median total score was 9 of 16 (interquartile range 7-11) and 1 of 3 (IQR 1-2) in infarction points. No correlation between ECG interpretation skill and factors such as education and professional experience was found, except that coronary care unit experience was associated with better results on the ECG test. Ambulance nurses have deficiencies in their ECG interpretation skills. This also applies to conditions where the ambulance crew has great potential to improve the outcome of the patient's health, such as myocardial infarction and cardiac arrest. Neither education, extensive experience in ambulance service nor in nursing contributed to an improved result. The only factor of importance for higher ECG interpretation knowledge was prior experience of working in a coronary care unit.

Electrocardiographic Interpretation Skills of Cardiology Residents: Are They Competent?

Achieving competency at electrocardiogram (ECG) interpretation among cardiology subspecialty residents has traditionally focused on interpreting a target number of ECGs during training. However, there is little evidence to support this approach. Further, there are no data documenting the competency of ECG interpretation skills among cardiology residents, who become de facto the gold standard in their practice communities. We tested 29 Cardiology residents from all 3 years in a large training program using a set of 20 ECGs collected from a community cardiology practice over a 1-month period. Residents interpreted half of the ECGs using a standard analytic framework, and half using their own approach. Residents were scored on the number of correct and incorrect diagnoses listed. Overall diagnostic accuracy was 58%. Of 6 potentially life-threatening diagnoses, residents missed 36% (123 of 348) including hyperkalemia (81%), long QT (52%), complete heart block (35%), and ventricular tachycardia (19%). Residents provided additional inappropriate diagnoses on 238 ECGs (41%). Diagnostic accuracy was similar between ECGs interpreted using an analytic framework vs ECGs interpreted without an analytic framework (59% vs 58%; F1,1333 = 0.26; P = 0.61). Cardiology resident proficiency at ECG interpretation is suboptimal. Despite the use of an analytic framework, there remain significant deficiencies in ECG interpretation among Cardiology residents. A more systematic method of addressing these important learning gaps is urgently needed.

Should we pay the student? A randomised trial of financial incentives in medical education

Background: Financial incentives are effective in moderating physician and patient behaviour, but they have not been studied in the context of medical education.Aim: This study assessed whether financial incentives can motivate students to acquire electrocardiogram (ECG) interpretation skills.Methods: Students enrolled for a cardio-respiratory teaching module (n = 121) were randomised to an intervention (financial incentive) or a control (book voucher raffle) condition. All students took three validated exams of ECG interpretation skills (at module entry, module exit and seven weeks later). Only the exit exam was financially incentivised in the intervention group. The primary outcome was the proportion of students who correctly identified ≥60% of clinically important diagnoses in the exit exam.Results: Financial incentives more than doubled the odds of correctly identifying ≥60% of diagnoses in the exit exam (adjusted odds ratio 2.44, 95% confidence interval 1.05–5.67) and significantly increased student learning time. However, there was no significant effect on performance levels in the retention exam.Conclusions: Financial incentives increase reported learning time and examination results in the short-term. The lack of a sustained effect on performance suggests that financial incentives may foster a superficial or strategic rather than a deep approach to learning.

Summative assessments are more powerful drivers of student learning than resource intensive teaching formats

BackgroundElectrocardiogram (ECG) interpretation is a core clinical skill that needs to be acquired during undergraduate medical education. Intensive teaching is generally assumed to produce more favorable learning outcomes, but recent research suggests that examinations are more powerful drivers of student learning than instructional format. This study assessed the differential contribution of teaching format and examination consequences to learning outcome regarding ECG interpretation skills in undergraduate medical students.MethodsA total of 534 fourth-year medical students participated in a six-group (two sets of three), partially randomized trial. Students received three levels of teaching intensity: self-directed learning (two groups), lectures (two groups) or small-group peer teaching facilitated by more advanced students (two groups). One of the two groups on each level of teaching intensity was assessed in a formative, the other in a summative written ECG examination, which provided a maximum of 1% credit points of the total curriculum. The formative examination provided individual feedback without credit points. Main outcome was the correct identification of ≥3 out of 5 diagnoses in original ECG tracings. Secondary outcome measures were time spent on independent study and use of additional study material.ResultsCompared with formative assessments, summative assessments increased the odds of correctly identifying at least three out of five ECG diagnoses (OR 5.14; 95% CI 3.26 to 8.09), of spending at least 2 h/week extra on ECG self-study (OR 4.02; 95% CI 2.65 to 6.12) and of using additional learning material (OR 2.86; 95% CI 1.92 to 4.24). Lectures and peer teaching were associated with increased learning effort only, but did not augment examination performance.ConclusionsMedical educators need to be aware of the paramount role of summative assessments in promoting student learning. Consequently, examinations within medical schools need to be closely matched to the desired learning outcomes. Shifting resources from implementing innovative and costly teaching formats to designing more high-quality summative examinations warrants further investigation.

Electrocardiogram interpretation skills in psychiatry trainees

Aims and methodTo assess the competence of psychiatry trainees in identifying major abnormalities in a 12-lead electrocardiogram (ECG). This was a three-stage prospective study. In stage 1, selected ECG traces were presented to the trainees. They were then asked to comment on any abnormalities of note on the ECG traces. In stage 2, an ECG e-book was made available to the trainees and the survey repeated. In stage 3, ECG workshop sessions were introduced in the mandatory teaching programme and the survey was repeated.ResultsThe number of correct responses after the introduction of the workshops were significantly more when compared with correct responses in stage 2 (P= 0.0002), and stage 1 (P= 0.0091). When compared with stage 1, the correct responses in stage 2 actually showed deterioration (P= 0.0284).Clinical implicationsOur study not only shows that providing access to an e-book is not enough to improve these skills, it also shows that ECG refresher sessions improved the diagnostic accuracy markedly.

Assessment of Competency in Electrocardiogram Interpretation of Graduating Physician Assistant Students

This study assessed the competency in electrocardiogram (ECG) interpretation of the 2011 physician assistant (PA) class at George Washington University School of Medicine and Health Sciences. A survey and 22-item ECG examination were completed by 51 students prior to graduation. Six strips were critical ECGs. The students scored 50.7% on the 22 ECGs and 68.0% on the six critical ECGs. Students who were more confident regarding their ability to accurately interpret ECGs and those who took a cardiology elective performed statistically significantly better on the 22 ECG examination (P = .005 and P = .032 respectively) but not on the six critical ECGs (P = .130 and P = .132 respectively). There were no significant associations between scores on either the 22 ECGs or six critical ECGs and students' perceived sufficiency of ECG training and desire for more ECG training. The students' overall scores indicate the need for improved training in ECG interpretation skills.

Towards outcome-based programme evaluation: Using student comparative self-assessments to determine teaching effectiveness

Background: Programme evaluation of medical education should be multi-dimensional. While structural and organisational aspects of teaching are frequently assessed, programme evaluation tools are rarely matched to specific learning objectives.Aims: This study used one medical school's catalogue of specific learning objectives to implement and critically appraise a novel programme evaluation tool based on comparative student self-assessments.Method: Medical students enrolled in the clinical phase of the undergraduate curriculum in Göttingen were invited to self-rate their knowledge, skills and attitudes before and after each course. A newly developed formula controlling for student performance levels when entering a course was used to compute a percentage gain in knowledge, skills and attitudes. Data derived from a prospective, longitudinal intervention study on the development of electrocardiogram interpretation skills including 636 students from four consecutive cohorts were used to provide validity evidence of the new approach.Results: The novel tool appeared superior to plain mean differences and effect sizes in detecting outstanding teaching as well as shortcomings of the curriculum. In addition, it adequately reflected objectively measured performance levels and was responsive to curriculum change.Conclusions: Comparative student self-assessment is a valid tool to appraise undergraduate medical curricula at the level of specific learning objectives.

ECG interpretation skills of South African Emergency Medicine residents

BackgroundThe use and interpretation of electrocardiograms (ECGs) are widely accepted as an essential core skill in Emergency Medicine. It is imperative that emergency physicians are expert in ECG interpretation when they exit their training programme.AimIt is unknown whether South African Emergency Medicine trainees are getting the necessary skills in ECG interpretation during the training programme. Currently there are no clear criteria to assess emergency physicians’ competency in ECG interpretation in South Africa.MethodsA prospective cross-sectional study of Emergency Medicine residents and recently qualified emergency physicians was conducted between August 2008 and February 2009 using a focused questionnaire.ResultsAt the time of the study, there were 55 eligible trainees in South Africa. A total of 55 assessments were distributed; 50 were returned (91%) and 49 were fully completed (89%). In this study, we found the overall average score of ECG interpretation was 46.4% [95% confidence interval (CI) 41.5–51.2%]. The junior group had an overall average of 42.2% (95% CI 36.9–47.5%), whereas the senior group managed 52.5% (95% CI 43.4–61.5%).ConclusionIn this prospective cross-sectional study of Emergency Medicine residents and recently qualified emergency physicians, we found that there was improvement in the interpretation of ECGs with increased seniority. There exists, however, a low level of accuracy for many of the critical ECG diagnoses. The average score of 46.4% obtained in this study is lower than the scores obtained by other international studies from countries where Emergency Medicine is a well-established speciality.

Impact of teaching and assessment format on electrocardiogram interpretation skills

Interpretation of the electrocardiogram (ECG) is a core clinical skill that should be developed in undergraduate medical education. This study assessed whether small-group peer teaching is more effective than lectures in enhancing medical students' ECG interpretation skills. In addition, the impact of assessment format on study outcome was analysed. Two consecutive cohorts of Year 4 medical students (n=335) were randomised to receive either traditional ECG lectures or the same amount of small-group, near-peer teaching during a 6-week cardiorespiratory course. Before and after the course, written assessments of ECG interpretation skills were undertaken. Whereas this final assessment yielded a considerable amount of credit points for students in the first cohort, it was merely formative in nature for the second cohort. An unannounced retention test was applied 8 weeks after the end of the cardiovascular course. A significant advantage of near-peer teaching over lectures (effect size 0.33) was noted only in the second cohort, whereas, in the setting of a summative assessment, both teaching formats appeared to be equally effective. A summative instead of a formative assessment doubled the performance increase (Cohen's d 4.9 versus 2.4), mitigating any difference between teaching formats. Within the second cohort, the significant difference between the two teaching formats was maintained in the retention test (p=0.017). However, in both cohorts, a significant decrease in student performance was detected during the 8 weeks following the cardiovascular course. Assessment format appeared to be more powerful than choice of instructional method in enhancing student learning. The effect observed in the second cohort was masked by an overriding incentive generated by the summative assessment in the first cohort. This masking effect should be considered in studies assessing the effectiveness of different teaching methods.

Electrocardiogram interpretation skills in pediatric residents

Objective:The primary objective of this study was to evaluate pediatric residents' ability to correctly identify electrocardiogram (ECG) findings and pair them to a corresponding cardiac diagnosis.Methods:Forty-six pediatric residents from the Johns Hopkins Children's Center were surveyed to evaluate their ability to interpret ECGs and factors affecting that ability. Included in the survey was a packet of 10 patient vignettes each accompanied by a 12-lead ECG. The primary outcome variable was the resident's score of correctly paired ECG findings with the appropriate cardiac diagnosis. One point was given for each pair correctly identified for a maximum of 10 points. Simple and multiple linear regression was used to estimate the magnitude and significance of any association between score of correct responses and resident year, completion of a pediatric cardiology rotation, self-rated ability to read ECGs, and training received in reading ECGs.Results:The mean number of correct ECG findings and cardiac diagnosis pairings out of 10 for the PGY 1 group was 4.1 ± 3, PGY 2 group 4.9 ± 2.9, PGY 3 group 6.6 ± 2, and the PGY 4 group 6.8 ± 1.7. In the unadjusted linear regression model, the PGY 3 group correctly identified 2.4 more pairings compared to the PGY 1 group (P =0.02). Those who completed a pediatric cardiology rotation correctly identified 2.5 more pairings compared to those who did not complete a rotation (P=0.001).Conclusions:ECG interpretation significantly improved from PGY 1 to PGY 3. Educational programs involving ECG interpretation should target those diagnoses with high clinical severity and average to poor resident knowledge.

Methods of teaching and evaluating electrocardiogram interpretation skills among cardiology fellowship programs in the United States

Background This study examines the methods used by cardiology training programs within the United States to teach electrocardiogram (ECG) interpretation and prepare fellows for the American Board of Internal Medicine board examination. Methods A link to an 18-question Web-based survey was electronically mailed to 198 fellowship directors in the United States. Results The response rate was 45%. Most participating programs were university hospitals or affiliates (77%) and of moderate size (at least 11 total fellows [72%]). Programs were coordinated by senior (68%) general (60%) cardiologists. Only 42% of the programs performed formal testing. The American Board of Internal Medicine answer sheet was used by most faculty (92%) when teaching ECG interpretation. Conclusions Teaching of ECG interpretation varies among US fellowship programs. Coordination of curricula is performed by senior faculty, likely reflecting a trend toward subspecialization and dilution of ECG expertise among younger faculty. Future endeavors should focus on curriculum standardization with regular competency assessment.

Junior psychiatrists' electrocardiogram interpretation skills

Aims and MethodWe checked whether psychiatric junior doctors could identify common electrocardiogram (ECG) abnormalities. Participants were directly approached at three London sites during induction or teaching programmes.ResultsThe survey had a total response rate of 65% (36/55). Psychiatry junior doctors displayed an overall success rate of 97% in detecting whether an ECG is grossly abnormal, but were much less competent in specifying exact ECG diagnoses (success rate of 41%). Accuracy rates for some diagnoses (e.g. paced rhythm) fell to as low as 11%. General practitioners performed no better than psychiatry trainees.Clinical ImplicationsThere is little consensus about minimum acceptable standards in medical skills such as ECG reporting in junior doctors. These competencies are generally ignored in new curriculums. Questions regarding the appropriate remit of psychiatry doctors in this area are raised and the need for more monitoring and education of these skills is queried.

Comparing IM Residents with EM Resident for Their Skills of ECG Interpretation and Outlining Management Plan Accordingly

Background and Purpose: Electrocardiogram (ECG) is one of the most commonly performed investigations in cardiac diseases and ECG abnormalities can reveal the early manifestations of cardiac ischemia, metabolic disorders, or life-threatening disrhythmias. Misinterpretation of ECG and its consequent mistreatment or performing inessential interventions may cause life-threatening cardiac events. Since EM residents and internal medicine (IM) residents are usually the first to visit at bedside and start treatments based on patient’s ECG, we intended to evaluate the ability of EM residents to interpret ECGs and to compare it with that of IM residents using various ECG samples. Method: 63 participants including 33 IM residents and 30 EM residents from two education hospitals of Shahid Beheshti University of Medical Sciences were enrolled in our study. A diagnosis test consisting of 15 ECG samples associated with a questionnaire containing questions about gender, academic year and proficiency in ECG interpretation was taken from all participants. This study was conducted under the supervision of a cardiologist and an emergency specialist who supervised the ECG selection, answers and scoring of each ECG. The maximum score for each ECG was 6 which were given to a completely correct diagnosis and -0.25 negative point was given if the answer was wrong or any differential diagnosis was mentioned. After the test, the answer sheets were collected and were analyzed with SPSS program, by two of study authors who were kept blind to the real identities of participants. Results: After classification of groups, the overall mean score was 45.5/100 (38-60). The mean score of IM and EM residents was 56.0/100 (44.9-72) and 38.9/100 (31.5-45.5), respectively (p< 0.001). No significant correlation was found between the diagnosis scores and participant’s self-judgment on her/his ECG interpretation skills (p=0.897, r=0.017). Five ECGs were considered as the most important and analysis revealed the overall mean score (out of 6) of participants was 5 for MI, 4.4 for ventricular tachycardia, 1.18 for pericarditis, 5.91 for WPW, and 5.09 for pulmonary emboli. Conclusion: our study revealed that the overall scores in ECG interpretation are low and the ECG interpretation skill in IM residents was better compared to EM residents. We demonstrated that there are several weaknesses in ECG interpretation which may have an important role in treatment of patients. Therefore there is a need for more and better ECG training programs especially in cardiac emergencies. Key Words: ECG INTERPRETATION, EMERGENCY MEDICINE RESIDENTS, INTERNAL MEDICINE RESIDENTS

97: 12-Lead Electrocardiogram Interpretation Skills of Senior Medical Students Entering Emergency Medicine, Family Practice, and Internal Medicine Residency Training Programs

Electrocardiogram (ECG) interpretation is an important clinical skill for senior medical students (MS) entering emergency medicine (EM), family practice (FP), and internal medicine (IM) residency programs. Research shows senior MS have deficiencies in ECG interpretation and that these skills do not change over the final year of medical school. However, little information is available describing these skills among senior MS entering these programs. This study aims to describe how residency aspiration impacts ECG interpretation skills.

12-Lead Electrocardiogram Interpretation Skills of Senior Medical Students

12-Lead Electrocardiogram Interpretation Skills of Senior Medical Students

Electrocardiogram interpretation in general practice

The 12-lead electrocardiogram (ECG) is a common diagnostic test available to the GP in the evaluation of patients with cardiac complaints. In daily clinical practice it is important for GPs to know the sensitivity and specificity of their ECG interpretation skills. The purpose of the present study was to evaluate the ECG interpretation skills of GPs and the value of automatic ECG recorder interpretations in general practice. A total of 902 ECGs were recorded in a random sample of the population aged 31-51 years in the district of Ebeltoft, Denmark, from December 1991 to June 1992. They were interpreted automatically by an interpretive ECG recorder and by the GPs in the clinic in Ebeltoft, with a cardiologists interpretation as a gold standard. Sensitivity, specificity and predictive values of diagnoses were calculated. Overall, the sensitivity of abnormal diagnoses made by the GPs (69.8%) was significantly lower (P <0.001) than that of diagnoses made by the interpretive ECG recorder (84.4%). The overall specificity of abnormal diagnoses made by the GP (85.7%) was significantly higher (P <0.001) than that achieved by the interpretive ECG recorder (75.6%). GPs in this study were good at correcting false-positive diagnoses made by the interpretive ECG recorder. In order to avoid unfortunate reclassifications of true-positive to false-negative diagnoses, GPs are recommended to pay special attention to the diagnoses of ST-segment deviation, T-wave inversion or the presence of Q-waves made by interpretive ECG recorders, when ECGs are used in individual risk assessment.

Can Pediatric Residents Interpret Electrocardiograms?

The purpose of this study was to assess the electrocardiogram (ECG) interpretation skills of pediatric residents in a controlled environment and determine if the level of residency training (intern vs senior) improves accuracy. A list of ECG diagnoses was provided to four pediatric residency educators with instructions to categorize each diagnosis as follows: I, all residents; II, the majority of residents, including all senior residents; III, less than the majority of residents; and IV, few residents should be able to interpret correctly. Only those categories that the entire panel believed all residents (category I) or all senior residents (category II) should be able to interpret correctly were included. The test included 17 ECGs: 14 category I and 3 category II. A total of 132 residents participated: 78 interns and 54 seniors. Both groups scored below expected levels. Mean correct score among seniors was 10.9 out of the expected 17 (p < 0.001). Mean correct score for interns was 7.7 out of the expected 14 (p < 0.00l). No difference in ECG interpretation accuracy was found between residency programs. In general, pediatric residents' ECG interpretation skills are less accurate than expected. Although there is a trend toward improvement during training, senior residents fell short of the expectations of the panel. We speculate that focused education in this area will improve resident ECG interpretation and benefit patient care by (1) facilitating referral and treatment of patients with cardiovascular disease and (2) decreasing referrals for erroneous interpretations.

Competency in interpretation of 12-lead electrocardiograms: a summary and appraisal of published evidence.

There have been many proposals for objective standards designed to optimize training, testing, and maintaining competency in interpretation of electrocardiograms (ECGs). However, most of these recommendations are consensus based and are not derived from clinical trials that include patient outcomes. To critically review the available data on training, accuracy, and outcomes of computer and physician interpretation of 12-lead resting ECGs. English-language articles were retrieved by searching MEDLINE (1966 to 2002), EMBASE (1974 to 2002), and the Cochrane Controlled Trials Register (1975-2002). The references in articles selected for analysis were also reviewed for relevance. All articles on training, accuracy, and outcomes of ECG interpretations were analyzed. Study design and results were summarized in evidence tables. Information on physician interpretation compared to a "gold standard," typically a consensus panel of expert electrocardiographers, was extracted. The clinical context of and outcomes related to the ECG interpretation were obtained whenever possible. Physicians of all specialties and levels of training, as well as computer software for interpreting ECGs, frequently made errors in interpreting ECGs when compared to expert electrocardiographers. There was also substantial disagreement on interpretations among cardiologists. Adverse patient outcomes occurred infrequently when ECGs were incorrectly interpreted. There is no evidence-based minimum number of ECG interpretations that is ideal for attaining or maintaining competency in ECG interpretation skills. Further research is needed to clarify the optimal way to build and maintain ECG interpretation skills based on patient outcomes.

Are family practice residents able to interpret electrocardiograms?

Teaching electrocardiogram (ECG) interpretation is a recommended component of the family practice residency curriculum. Published information concerning the ECG interpretation ability of residents is sparse. This study sought to ascertain the baseline knowledge of family practice residents' ECG interpretation skills and extent of improvement after one year of training. A 15 ECG examination was administered to 38 PG-1 and 14 upper level residents at 5 residency programs at the beginning of the academic year and to residents at the authors' program at the end of the academic year. Pre-test scores among the five programs were compared using an analysis of variance (ANOVA). Pre-test and post-test scores were compared using a paired randomization test. No difference was found between average scores from each site, or between the beginning and end of the academic year. Residents were more likely to misinterpret items such as myocardial infarction, myocardial ischemia, and atrial fibrillation. Residents in family practice have considerable deficiencies in ECG interpretation skills. Further studies are needed to determine effective ECG teaching curricula.