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
Methods of Teaching
Various instructional mediums have been successfully implemented to teach ECG interpretation competencies, including lectures, puzzles, web-based programs, iBooks, and YouTube.34-41-44,47,48.51-53 A survey of clerkship directors in internal medicine revealed that 75% of clerkship programs teach ECG interpretation in a classroom lecture-based setting, 44% use teaching rounds, and only 17% utilize online/web-based instruction.3 Canadian family medicine programs have a relatively equal distribution between classroom-based, computer-based, and bedside teaching.5
In comparing the efficacy of instructional styles, several small comparative studies favor an electronic teaching format because of the enhanced learner interaction and visual learning, but there does not appear to be a consistently proven large advantage of 1 teaching format over another.43,48,51,54 The overall theme emerging from this literature is the importance of repetition and active engagement in ECG interpretation, which appear to be more important than 1 particular strategy.22 Computer-based training appears to deliver these 2 qualities, unlike the traditional lecture-style passive learning model. The concept of repetition and engagement is also well supported in medical education literature outside ECG interpretation.55,56
Given these data, we recommend that each medical education program select teaching methods based on their available resources, as long as adequate teaching time is allotted to ensure that trainees acquire the competencies defined in this publication.
Assessment Methods
It appears that the larger factor in determining ECG interpretation performance is not the learning format, but the form of assessment. Two studies have demonstrated that summative assessment substantially improves ECG interpretation performance when compared with formative assessment; in fact, this effect was so large that it overshadowed any small difference in teaching formats.57,58 This concept aligns with medical education literature, which acknowledges that assessment drives learning by raising the stakes, thereby boosting student effort and encouraging learning to an effect much larger than can be generated by any particular learning style.57,59 Nevertheless, well-designed formative assessment can focus students on effective learning by identifying gaps and important information.60 Only 33% of Canadian family medicine residency programs and 71% of American clerkship programs have formal assessment of ECG interpretation skills.3,5 There is no doubt that assessment, both formative and summative, should be implemented in all undergraduate and postgraduate medical training programs. Online assessment methods have the advantage of delivering high-quality images and a variety of question formats; hence, their use should be encouraged.36,50,61-63
Teaching Personnel and Timing of Training
Who should teach ECG interpretation and when should this teaching take place? ECG interpretation in training programs is typically taught by attending physicians in each respective field. However, given that there is a large ECG interpretation error rate by noncardiologist physicians, we advise that ECG training content be created with input from own-specialty attending physicians and cardiologists.4 This teaching should take place early in medical school at the time medical students learn pathophysiology of the heart and should continue throughout training. Longitudinal training is preferred to block-based training because of improved resident satisfaction, but medical education literature did not reveal a difference in student performance with either strategy.64-66
CONCLUSIONS
Despite its immense clinical value, there continues to be a lack of a comprehensive ECG interpretation curriculum in medical education programs. The goal of this position paper is to encourage the development of organized curricula in undergraduate and postgraduate medical education programs, and to ensure the acquisition of level-appropriate ECG interpretation skills while maintaining patient safety. We assist this process by grouping ECG findings into 4 classes (A to D) based on the frequency of encounter and emergent nature and by assigning them to each level of training. Methods of teaching ECG interpretation are less important and can be selected based on the available resources of each education program and student preference; however, online learning is encouraged. We also recommend that summative trainee evaluation methods be implemented in all programs to ensure that appropriate competencies are acquired and to further encourage self-directed learning. Resources should be allocated to ensure that every trainee is reaching their training milestones and should ensure that no electrocardiographic emergency (class A condition) is ever missed by a trainee. We hope that these guidelines will inform medical education systems and help prevent adverse patient outcomes caused by the misinterpretation of this valuable clinical diagnostic tool.
Disclosure
On behalf of all authors, the corresponding author states that there is no conflict of interest. This manuscript did not utilize any sources of funding.
