Are ECGs really that challenging and how can you simplify the process?

Summary

ECG interpretation is challenging due to complex waveforms and the need for quick decisions. This post explores potential reasons as to why it’s difficult and offers a solution, a 5-step structured approach. Master ECGs with clarity and confidence using this simple, systematic method.

Many struggle with ECG interpretation

The ECG is one of the most commonly requested diagnostic tools in the USA; there are estimated to be more than 300 million ECGs requested annually.¹ Therefore, it is not surprising that basic proficiency in interpreting ECGs is required in medical practice. Despite this, many rely on the computerised interpretation provided by the ECG machine.¹ Additionally, there is currently no accepted standard to assess for ECG competency to further guide learning and skill development.¹

One study conducted in South Africa aimed to assess a sample of medical practitioners’s ability to accurately interpret and diagnose ECGs.² Category outcomes of interest include: primary ECG parameters (such as the rate, rhythm and axis), ECG emergencies and common ECG abnormalities. Overall the level of correctness achieved by all practitioners was 14.7%. Most (70%) were general practitioners, and most ( >70%) had more than 15 years of clinical experience.²

Another study, also conducted in South Africa, assessing accuracy amongst emergency medicine residents and recently qualified emergency medicine physicians showed an average accuracy of 46.4%.³

These outcomes suggest that there is generally poor competency in ECG interpretation. This is in keeping with other research conducted to assess ECG interpretation. A meta-analysis that included 78 studies found that there may be deficiencies in ECG interpretation across all training levels (medical students, residents, practising physicians, and cardiologists). However, on average median accuracy improved with each training level.⁴

“…there is generally poor competency in ECG interpretation. This is in keeping with other research conducted to assess ECG interpretation”

Why is learning to interpret ECGs challenging?

There are few theories and reasons that have been identified in the literature to try to explain why ECG interpretation is particularly challenging for not only medical students, but also medical practitioners. Some of these reasons have been listed below:

The perceived imbalance between effort and reward: Many may feel that the time and effort investing in mastering ECG interpretation often fails to yield noticeable improvements in proficiency in proportion to the time and effort contributed.¹ Additionally, many may rely on the computerised interpretation of the ECG produced by the machine. This may result in individuals devaluating this skill and prompting them to focus on developing other clinical skills where progress and results are more tangible.¹
ECG interpretation requires bridging knowledge domains and skill: ECG interpretation is a multifaceted skill that requires the integration of diverse knowledge domains and the application of critical thinking. It particularly involves understanding anatomy, electrophysiology, and pathophysiology, and whilst also exercising pattern recognition and diagnostic reasoning. This combination of foundational knowledge and applied skills is likely to contribute to what makes ECG interpretation challenging.^1,4

The current medical curriculum is overwhelming: The medical school curriculum is known to be dense with an overwhelming amount of content to be covered across medical disciplines. This leaves little time to teach and master ECG interpretation despite its recognised importance in clinical practice which makes ECG mastery challenging.¹

A proposed solution

At Four Minute Medicine we have created a 10-hour course that helps develop the multi-domain knowledge and skills required for ECG interpretation. Additionally, this is a focused and a time-efficient method to learning ECGs. Furthermore, it comprehensively covers a 5-step process to ECG interpretation. This process aims to demystify and simplify ECG interpretation. However, to fully appreciate these steps one needs to ensure adequate foundational knowledge which includes: anatomy, electrophysiology, and pathophysiology, exercising pattern recognition, and diagnostic reasoning. All of this is included in the course.

The Four Minute Medicine ECG Mastery course offers a time-wise approach to ECG interpretation through the use of a simple and intuitive 5-step process.

Introducing the 5-step process

The 5-step process starts by analysing the rhythm then systematically works through the different wave forms, in order, as seen on the ECG trace. This process is further outlined below.

Step 1: Analyse the rhythm

The first step is to determine the general location of the cardiac pacemaker and to describe the key characteristics of the cardiac pacing. Focus on two key characteristics of the rhythm:

Rate: is it fast or slow? , Regularity: is it regular or irregular?

Essentially, the goal is to answer the following questions:

“Where is the cardiac pacemaker? Above or within the ventricles?”

“How is the electrical impulse firing: fast or slow, regularly or irregularly?”

Step 2: Describe the p wave

The p wave represents atrial depolarisation therefore assessing the p wave can provide some information regarding the physiological and anatomical status of the atria. Additionally, this step helps to confirm whether the cardiac pacemaker is at the sinoatrial node.

In step 2 the aim is to answer the following question: “Are the atria structurally and physiological normal?”

Additionally, if a rhythm is found to have a supraventricular origin in step 1, one can answer this question: “Is the sinoatrial node the likely location of the supraventricular rhythm?”

Step 3: Assess the PR interval and segment

The PR interval represents the movement of the electrical activity between the atria and ventricles.

If the interval is short this suggests that there is an accessory pathway, meaning that the electrical activity from the atria reaches the ventricles via an alternative pathway.

If the PR interval is prolonged this suggests a block meaning that there is an obstruction impeding normal conduction between the atria and ventricles, and this is known as a heart block. The question answered during this step is: “Does the electrical activity move normally between the atria and ventricles?”

Step 4: Describe the QRS complex

The QRS complex represents ventricular depolarisation, and therefore upon review of the complex can identify structural and physiological abnormalities at the level of the ventricles such as ventricular hypertrophy, bundle branch blocks and fascicular blocks.

The question to be addressed during this step is: “Are the ventricles structurally and physiological normal?”

Step 5: Review the ST segment and the T wave

The ST segment and T wave are related to ventricular repolarisation. Therefore, like step 4, step 5 can provide information regarding the structural and physiological status of the ventricles.

By completing this step one may be able to identify ischaemia, infarction and electrolyte imbalances such as hyperkalaemia.

Mastering ECG interpretation may seem like an insurmountable task, but with the right approach and resources it can become an achievable and rewarding skill. The 5-step process aims to create a structured approach to ECG interpretation that aims to remove complexity so that you can interpret ECGs with confidence. If you would like to start your journey towards ECG mastery our course offers everything that you may need, including foundational and example driven learning at each step. This course was designed with busy medical students and practitioners in mind; it offers a time-wise approach to ECG mastery. Remove the guesswork to ECG interpretation, let’s start our journey together.

Click here to join the course and start mastering ECGs today!
Prefer a live session? Sign up for our 2-hour ECG Essentials webinar. Register now!

REFERENCES

Kashou A, May A, DeSimone C, Noseworthy P. The essential skill of ECG interpretation: How do we define and improve competency?. Postgrad Med J. 2020;96(1133):125-127. doi:10.1136/postgradmedj-2019-137191
Mabuza LH, Mntla PS. Generalist practitioners’ self-rating and competence in electrocardiogram interpretation in South Africa. Afr J Prim Health Care Fam Med. 2020;12(1):e1-e7. Published 2020 Aug 24. doi:10.4102/phcfm.v12i1.2421
de Jager J, Wallis L, Maritz D. ECG interpretation skills of South African Emergency Medicine residents. Int J Emerg Med. 2010;3(4):309-314. Published 2010 Oct 28. doi:10.1007/s12245-010-0227-3
Cook DA, Oh SY, Pusic MV. Accuracy of Physicians’ Electrocardiogram Interpretations: A Systematic Review and Meta-analysis. JAMA Intern Med. 2020;180(11):1461-1471. doi:10.1001/jamainternmed.2020.3989

How to read ECGs: Our 5-Step-process