Junior psychiatrists' electrocardiogram interpretation skills

AIMS AND METHOD

We checked whether psychiatric junior doctors could identifycommon electrocardiogram (ECG) abnormalities. Participantswere directly approached at three London sites during inductionor teaching programmes.

RESULTS

The survey had a total response rate of 65% (36/55). Psychiatryjunior doctors displayed an overall success rate of 97% indetecting whether an ECG is grossly abnormal, but were muchless competent in specifying exact ECG diagnoses (success rateof 41%). Accuracy rates for some diagnoses (e.g. paced rhythm)fell to as low as 11%. General practitioners performed no betterthan psychiatry trainees.

CLINICAL IMPLICATIONS

There is little consensus about minimum acceptable standardsin medical skills such as ECG reporting in junior doctors.These competencies are generally ignored in new curriculums.Questions regarding the appropriate remit of psychiatry doctorsin this area are raised and the need for more monitoring andeducation of these skills is queried.

Introduction

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Introduction

Junior psychiatry doctors have diverse responsibilities bothin their day-to-day work and in their role as an on-call doctor.They are usually responsible for the physical health of theirpatients who often have comorbid medical conditions and vascularrisk factors such as smoking and diabetes. There has been renewedinterest in excess morbidity due to cardiovascular events (Brown & Barraclough, 2000)and the role that psychiatric interventions, particularly atypicalantipsychotics, have in increasing risk (Lambert & Chapman, 2004). The interaction between psychotic illness, metabolic syndromeand antipsychotic drugs is of particular concern (Anai-Otong, 2004).

Most individuals require a baseline electrocardiogram (ECG)on admission, often in anticipation of antipsychotic use. Specialgroups such as older adults, individuals with eating disordersand those receiving above maximum British National Formularyguideline doses often require more intensive ECG monitoring.A common on-call experience is attending to an individual with chest pain, who needs an urgent ECG to exclude cardiac origin. Electrocardiogram interpretation is usually the remit of theattending junior doctor. Psychiatric junior doctors often comefrom diverse backgrounds with varying prior general medicalexperience. Little is known about their general medical skills(such as ECG interpretation) which are rarely assessed during their psychiatric training.

Method

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Method

An ECG skills questionnaire was devised involving the interpretationof five electrocardiograms. For each, the doctor was askedwhether the ECG was normal or abnormal and, if abnormal, tostate the abnormality. The five ECGs were as follows:

left bundle branch block
atrial fibrillation
inferior myocardialinfarction
paced ventricular rhythm
normal.

Respondents were also asked to identify their senior house officerlevel as a psychiatry trainee year 1, 2, 3, 3+ or as a GeneralPractice Vocational Training Scheme trainee.

Junior psychiatry doctors at three hospitals in London wereapproached in person to complete the test. At two sites participantswere ‘captured’ on the first day of induction andat the third site before a tutorial in their formal teachingprogram. Questionnaires were completed anonymously and collectedas a batch the same day.

Results

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Results

The overall response rate was 65% (n=36/55). A previous pilotat one site relying on ECG questionnaires being sent back resultedin dismal response rate of 10%. The success rates of participantsbeing able to identify each ECG correctly as grossly normalor abnormal without having to specify the diagnosis is outlinedin Table 1.

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Table 1. Participants’ success rates in identifying grossly normal or abnormal ECG

Most junior doctors were highly accurate in identifying whetheran ECG was normal or abnormal, with a total average successrate of approximately 97%. The two abnormalities misinterpretedas normal were left bundle branch block and atrial fibrillation.Interpretation accuracy falls dramatically, however, if participantsare judged on their ability to name the ECG abnormality precisely.Success rates for this exercise are shown in Table 2.

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Table 2. Participants’ success rates in identifying an ECG abnormality

Beyond the recognition of atrial fibrillation (80% success rate),doctors struggled with identifying the other abnormalitiesof an inferior myocardial infarction (36%), left bundle branchblock (31%), and the paced rhythm (11%). However, if more approximateanswers were accepted (e.g. ‘bundle branch block’or ‘conduction abnormality’ for left bundle branch block or a more general term of ‘ischaemia’ forinferior myocardial infarction), interpretation ‘accuracy’for inferior myocardial infarction and left bundle branch blockimproved to 83% (n=30/36) and 58% (n=21/36) respectively. Theoverall interpretation accuracy was 40%.

Results stratified by trainee level/background are shown in Table 3. Average accuracies for identifying ECG as grosslynormal or abnormal and naming ECG abnormality correctly areshown.

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Table 3. Relationship between participants’ medical background and their success rates in identifying and naming ECG abnormalities

There were no marked differences noted when considering theeffect of trainee background on interpretation accuracy. Generalpractitioner trainees scored no better than their psychiatrycolleagues at ECG interpretation and in this sample were marginallyworse at identifying whether an ECG was grossly normal or abnormal.

Discussion

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Discussion

Overall, psychiatry junior doctors appeared reasonably competentat identifying an ECG as grossly normal or abnormal but muchless accurate at making exact ECG diagnoses. Perhaps the mostimportant skill is to know when to seek advice in situationsof uncertainty. Most consultants would hope that their juniorswould autonomously seek expert help when needed but it is unclearhow often these subjects are explicitly discussed in supervision (Cottrell, 1999). Computer-generated ECG reports cannot berelied on to help as they do not appear to reduce interpretationerrors in junior doctors (Goodacre & Webster, 2001).

There is little consensus about minimum acceptable standardsin ECG reporting in psychiatric trainees. The new Member ofthe Royal College of Psychiatrists (MRCPsych) curriculum andwork-based assessments generally ignore this competency. Onthe face of it, these results appear fairly respectable fora cohort of psychiatry trainees. Casualty senior house officers,by comparison, are known to have high error rates when interpreting ECGs (Goodacre & Webster, 2001). A 97% success rate is,of course, no consolation if you are the patient who has hadtheir ECG misread. In this study, both left bundle branch blockand atrial fibrillation were misinterpreted as normal on one occasion each. If, for example, arrhythmia were the acute resultof a myocardial infarction or some other serious pathology,the error could be fatal.

Most patients (and consultants) would obviously hope for completeaccuracy but the way to strive for and achieve this is uncertain.Many junior doctors during the study said they would welcomeformal training or refresher courses in ECG reading. Such coursesare available nationally but they are expensive. Moreover,their effectiveness is uncertain and there is no evidence-based minimum number of ECG interpretations that is considered idealfor maintaining interpretation skills (Salerno & Alguire, 2003).Local tutorials conducted by local cardiologists could be agood accessible starting point.

Shared care arrangements for patients are another possible solutionin reducing the ‘burden’ of preserving ECG interpretation(and other medical skills) in psychiatric doctors. Primarycare involvement and shared care is encouraged in NationalInstitute for Health and Clinical Excellence guidance for themonitoring of physical health of individuals with schizophrenia.Lester (2005, p. 134) suggested that, ‘Clear roles andresponsibilities around mental and physical healthcare withina shared care approach... might lead to better quality physicalcare and eventually to a reduction in morbidity and mortality rates’. An opposing view would be that this arrangementcan lead to medical de-skilling of psychiatrists.

Limitations
This study has several limitations. The absolute number of respondentsis low and results would have been amenable to formal statisticalanalysis if a larger group could have been tested. The responserate of 65% also makes a responder bias likely with the possibilityof weaker trainees not returning their surveys and inflatinginterpretation accuracy rates. It was apparent during our surveythat many psychiatric junior doctors were very nervous and reluctantto be tested on ‘rusty’ medical skills.

Despite these limitations, we have shown that psychiatry traineesappear to be reasonably competent in detecting whether an ECGis grossly abnormal, but are much less competent in specifyingexact ECG diagnoses. It is likely that trainees will be exposedto more ECGs in the future as part of a greater appreciationof the need to screen for physical illnesses in our patient groups. This increasing need should be reflected in postgraduatespecialty curriculums.

References

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