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
Each ECG interpretation strategy has its advantages, and we recommend that students be exposed to all available approaches if teaching resources are available.
Teaching Delivery Format
Each of the above teaching strategies can be delivered to students in various ways. The following teaching formats have been previously documented in the literature:
1. Classroom-based teaching: This is a traditional learning format that takes place in a large- or small-group classroom. Typically, these sessions are led by a single instructor, and they are focused on the direct sharing of information and group discussion.41
2. Electronic practice tools: Numerous electronic tools have been developed with the purpose of providing deliberate practice to master ECG interpretation. Some of these tools employ active learner engagement, while others provide a bank of ECGs for self-directed passive learning.42-46
3. Video lectures: Short video lectures have been created to facilitate self-directed lecture based learning. These lectures are hosted on a variety of web-based platforms, including YouTube and Vimeo.47
4. Traditional and electronic books: Numerous traditional textbooks have been published on ECG interpretation and are designed to facilitate independent learning. Some textbooks directly deliver teaching material, while others contain sets of ECGs to allow for repetitive practice. More recently, iBooks incorporating self-assessment tools have been used to assist ECG teaching.34 The advantage of these tools is that they can also be used to supplement in-person classes.
5. Games: A unique ECG interpretation learning strategy consists of using puzzles and games to learn ECGs. This is meant to improve student engagement and interest in learning ECG interpretation.48
Given that there is currently a lack of evidence-based data to support 1 instructional format over another, we do not favor any particular one. This decision should be left to instructors and individual learners based on their preference and available resources. Further studies would be helpful to determine the effectiveness of various methods in teaching ECG interpretation and to identify any additional specific factors that facilitate learning.
Evaluation Strategies
1. Longitudinal ongoing feedback: This form of feedback universally takes place in all training programs and focuses on direct observation and point-of-care feedback by a senior healthcare professional during clinical practice. Typically, the feedback is informal and is centered around specific case presentations.
2. Formative testing: This assessment strategy is aimed at monitoring the learning of trainees and providing them with appropriate feedback. Tutors and teachers can use this data to individualize instruction and fill any training gaps that individuals and the class may have. Students themselves can use this information to encourage additional study to ensure they acquire required skills. Examples of formative testing are low-stakes in-training exams and asking audience questions during a workshop or lecture.49
3. Summative testing: Summative assessments are created to measure the level of proficiency developed by a learner and compare it against some standard or benchmark. This form of assessment establishes the extent to which educational objectives have been met. The most common example is an end-of-term examination.
Online ECG examination has been successfully used to provide methods of testing. They are easy to distribute, highly convenient for learners, and allow the display of high-quality graphics. They can also be graded electronically, thereby minimizing the resources required to administer and grade exams.36,50
We recommend using a combination of assessment formats to ensure the optimal evaluation of learner skill and to focus learning on areas of weakness. Summative assessments are highly valuable to ensure learners acquired the necessary ECG interpretation competencies. Remediation strategies should be available to provide additional practice to learners who do not meet competencies expected at their level of training.
DISCUSSION
The Need for ECG Interpretation Competencies and Milestones
Since the introduction of ECG in the late 1800s, there continues to be a significant variation in ECG interpretation skills among trainees and medical professionals.4,6-12 Concerns continue to exist about the rate of missed diagnoses involving critical ECGs, leading to inappropriate patient management decisions. Despite the obvious need, teaching ECG interpretation is given little emphasis in medical education, and the curriculum remains quite disorganized. In this position paper, we call for a more structured ECG interpretation curriculum in medical education and hope to assist this process by assigning ECG patterns to 2 milestones in training: graduating medical students and first year postgraduate medical residents.
Defining competencies would help medical education programs to focus resources on teaching clinically important conditions for the appropriate level of training. We divide ECG findings into 4 categories (classes A to D), and we place emphasis on learning electrocardiographic emergencies early in training and spending less time on ECG findings that are unlikely to change patient management.
The goal is to ensure 100% recognition of class A (electrocardiographic emergencies) by the end of medical school. To ensure each medical education program fulfils this goal, a structured curriculum including a summative assessment is required.
