Correspondence from the world of cardiology
Dear Sirs,
I read with interest the article by Rowlands and Moore1 on the current variability in the competence among healthcare professionals including experienced clinicians interpreting electrocardiograms (ECGs). The fundamental point is raised about the patient safety risk that occurs across the National Health Service (NHS). A previous retrospective analysis of 1,000 single-centre emergency department cases and ECGs found that 38 patients had been discharged with ‘abnormalities that could potentially alter case management’.2 The route of variability in competence of ECG interpretation for doctors can be traced back to undergraduate and postgraduate training. Over the last two decades, there has been a seismic shift in the pattern of training both at medical school and as a junior doctor. Medical school curriculums have altered, with many having less taught time for procedural skills and relying more on clinical attachments. However, there is less time available to teach medical students clinical skills.3 Postgraduate training programmes vary in size and quality between locations of foundation programme rotations. This manifests in the lack of confidence and competence in clinical skill performance, which we have particularly noticed in ECG interpretation. The UK is attempting to provide a standardisation for competency in ECG interpretation for doctors in training. The Foundation Curriculum 2010 (updated 2012) outlines ECG diagnoses and features that should be recognised and correctly interpreted in the foundation year one (FY1) role.4 Despite this standardisation, there continues to be variation. We have demonstrated this variation in a small, prospective, randomised study examining confidence and competence in ECG interpretation in undergraduates and postgraduates.5
We hypothesised that undergraduates and postgraduates would have variable confidence and competence in ECG interpretation due to varying experiences in learning, and this could be improved by offering specific training sessions to their training level. We randomised 26 FY1 doctors and 36 third-year medical students (volunteers) to a group undertaking focused training sessions (FTP) or self-directed learning (SDL). The FTP instructor was blinded to randomisation. FY1 and third-year medical students had separate, tailored training sessions. Confidence and competence was evaluated using a questionnaire (before and after) and a multiple-choice questionnaire (set by two independent consultant cardiologists). Baseline confidence rating was variable within each group. The most concerning rating for confidence in FY1 doctors was ‘poor’ (19.1%) with the most common rating being ‘satisfactory’ (66.6%). The third-year medical students most frequently rated themselves as ‘very poor’ (60%). The baseline confidence evaluations were particularly concerning for the FY1 doctors, though there is an improvement for both groups after the learning intervention, especially for those that underwent FTP. Following both learning interventions, confidence improved for all volunteers, with the greatest improvement in both FTP groups. Confidence was rated for interpreting specific individual ECGs. Baseline confidence for third-year medical students was poor for all ECGs except ‘sinus rhythm’. FY1 doctors at baseline did rate themselves as more confident interpreting life-threatening ECGs (ventricular fibrillation and tachycardia), but frequently rated themselves poorly for left and right bundle branch block. Third-year medical students more frequently rated themselves as confident in interpreting all the specific ECGs on the questionnaire. There was an improvement in confidence for both FY1 groups, without there being a clear difference between FTP and SDL. Confidence in ‘bundle branch block’ interpretation remained low, despite intervention in both groups. For individual ECG interpretation competence there were no statistically significant differences between each FY1 group. The third-year medical students in the FTP group interpreted ‘ventricular tachycardia’ (p=0.046) and ‘narrow complex tachycardia’ (p=0.009) significantly better than their SDL counterparts.
Rowlands and Moore hit the nail on the head highlighting the variability in correct ECG interpretation. This is a problem that has its foundations in the learning to become competent. Many stratagems may help to improve competence, however, a focused teaching programme, as highlighted in this article, can be very effective. Our study was cost-neutral and the results demonstrated an improvement in confidence in both groups and competence in the third-year medical students. Our study was performed on small numbers, but highlights the current problem and one strategy that should be considered to improve the situation.
Conflict of interest
None declared.
Christopher McAloon, Speciality Registrar in Cardiology
([email protected])
Helen Leach, Foundation Year One Doctor
Simrat Gill, Core Medical Trainee
Jasper Trevelyan, Consultant Cardiologist
Worcestershire Acute NHS Trust, Charles Hastings Way, Worcester, WR5 1DD
Arun Aluwalia, Specialty Registrar in Public Health
Birmingham Heartlands Hospital NHS Trust, Bordesley Green, Birmingham, B9 5SS
References
1. Rowlands D, Moore P. ECG interpretation in the NHS. Br J Cardiol 2014;21:47–8. http://dx.doi.org/10.5837/bjc.2014.010
2. Todd KH, Hoffminan JR, Morgan MT. Effect of cardiologist ECG review on emergency department practice. Ann Emer Med 1996;27:16–21. http://dx.doi.org/10.1016/S0196-0644(96)70290-1
3. LaCombe MA. On bedside teaching, Ann Intern Med 1997;126:217–20. http://dx.doi.org/10.7326/0003-4819-126-3-199702010-00007
4. UK Foundation Programme Office. The UK Foundation Programme Curriculum 2010. Cardiff: UKFPO, 2010. Accessed at: http://www.nhsemployers.org/SiteCollectionDocuments/Foundation%20Programme%20Curriculum%202010.PDF [6 February 2013]. The up-to-date curriculum is available from: http://www.foundationprogramme.nhs.uk/index.asp?page=home/keydocs#c&rg
5. McAloon CJ, Leach H, Gill S, Aluwalia A, Trevelyan J. Improving ECG Competence in Medical Trainees in a UK District General Hospital. Cardiol Res 2014;5:51–7. http://dx.doi.org/10.14740/cr333e
