ECG Interpretation Proficiency of Healthcare Professionals

Abstract

Introduction:
ECG interpretation is essential in modern medicine, yet achieving and maintaining competency can be challenging for healthcare professionals. Quantifying proficiency gaps can inform educational interventions for addressing these challenges.

Methods:
Medical professionals from diverse disciplines and training levels interpreted 30 12-lead ECGs with common urgent and non-urgent findings. Average accuracy (percentage of correctly identified findings), interpretation time per ECG, and self-reported confidence (rated on a scale of 0 [not confident], 1 [somewhat confident], or 2 [confident]) were evaluated.

Results:
Among the 1206 participants, there were 72 (6%) primary care physicians (PCPs), 146 (12%) cardiology fellows-in-training (FITs), 353 (29%) resident physicians, 182 (15%) medical students, 84 (7%) advanced practice providers (APPs), 120 (10%) nurses, and 249 (21%) allied health professionals (AHPs). Overall, participants achieved an average overall accuracy of 56.4 ± 17.2%, interpretation time of 142 ± 67 seconds, and confidence of 0.83 ± 0.53. Cardiology FITs demonstrated superior performance across all metrics. PCPs had a higher accuracy compared to nurses and APPs (58.1% vs. 46.8% and 50.6%; P<0.01), but a lower accuracy than resident physicians (58.1% vs. 59.7%; P<0.01). AHPs outperformed nurses and APPs in every metric and showed comparable performance to resident physicians and PCPs.

Conclusions:
Our findings highlight significant gaps in the ECG interpretation proficiency among healthcare professionals.

Full text

&
Exploring Factors Influencing ECG
Interpretation Proficiency of Medical
Professionals
Anthony H. Kashou, MD
a
*, Peter A. Noseworthy, MD
a
,
Thomas J. Beckman, MD
b
, Nandan S. Anavekar, MD
a
,
Kurt B. Angstman, MD
c
, Michael W. Cullen, MD
a
,
Benjamin J. Sandefur, MD
d
, Paul A. Friedman, MD
a
,
Brian P. Shapiro, MD
e
, Brandon W. Wiley, MD
f
,
Andrew M. Kates, MD
g
, Andrew Braisted, MHSA
h
,
David Huneycutt, MD
h
, Adrian Baranchuk, MD
i
,
John W. Beard, MD
j
, Scott Kerwin, MN
j
,
Brian Young, MS
j
, Ian Rowlandson, MS
j
,
Stephen J. Knohl, MD
k
, Kevin O’Brien, MD
l
, and
Adam M. May, MD
g
From the
a
Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA,
b
Internal Medicine,
Mayo Clinic, Rochester, Minnesota, USA,
c
Family Medicine, Mayo Clinic, Rochester, Minnesota,
USA,
d
Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA,
e
Cardiovascular Medicine,
Mayo Clinic, Jacksonville, Florida, USA,
f
Cardiovascular Medicine, Keck School of Medicine,
University of Southern California, Los Angeles California, USA,
g
Cardiovascular Medicine,
Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA,
h
Cardiovascular
Medicine, HCA Healthcare, Nashville, Tennessee, USA,
i
Cardiovascular Medicine, Queen’s Univer-
sity, Kingston, Ontario, Canada,
j
GE HealthCare, Wauwatosa, Wisconsin, USA,
k
Internal Medicine,
SUNY Upstate Medical University, Syracuse, New York, USA and
l
Internal Medicine, University of
South Florida, Tampa, Florida, USA.
Abstract: The electrocardiogram (ECG) is a crucial diag-
nostic tool in medicine with concerns about its interpreta-
tion proficiency across various medical disciplines. Our
study aimed to explore potential causes of these issues and
identify areas requiring improvement. A survey was con-
ducted among medical professionals to understand their
The funding supported in part by GE HealthCare (Milwaukee, WI) and NIH T32 HL007111.
*Corresponding author: Anthony H. Kashou, MD, Department of Cardiovascular Medicine, Mayo Clinic, 200
First Street SW, Rochester, MN, 55905. E-mail: kashou.anthony@mayo.edu
Curr Probl Cardiol 2023;48:101865
0146-2806/$ see front matter
https://doi.org/10.1016/j.cpcardiol.2023.101865
Curr Probl Cardiol, October 2023 1

experiences with ECG interpretation and education. A
total of 2515 participants from diverse medical back-
grounds were surveyed. A total of 1989 (79%) partici-
pants reported ECG interpretation as part of their
practice. However, 45% expressed discomfort with inde-
pendent interpretation. A significant 73% received less
than 5 hours of ECG-specific education, with 45% report-
ing no education at all. Also, 87% reported limited or no
expert supervision. Nearly all medical professionals (2461,
98%) expressed a desire for more ECG education. These
findings were consistent across all groups and did not
vary between primary care physicians, cardiology FIT,
resident physicians, medical students, APPs, nurses, physi-
cians, and nonphysicians. This study reveals substantial
deficiencies in ECG interpretation training, supervision,
and confidence among medical professionals, despite a
strong interest in increased ECG education. (Curr Probl
Cardiol 2023;48:101865.)
Introduction
&
Medical providers are required to interpret 12-lead electrocardio-
grams (ECGs) efficiently and accurately. Incorrect ECG inter-
pretation can lead to misdiagnosis and delayed treatment or use
of inappropriate treatment methods. Therefore, competency in ECG inter-
pretation is an expectation for almost all medical providers.
1-6
Although the issue of ECG interpretation proficiency among medical
professionals is a longstanding concern, the underlying causes and the
scope of these inadequacies remain unclear.
5-15
Our goals in this study
were to investigate factors contributing to proficiency deficiencies in
ECG interpretation and identify potential areas for improvement. A better
understanding of these factors will enable the development of compre-
hensive, scalable, and widely accessible educational solutions that can
effectively address gaps in ECG interpretation proficiency.
Methods
Study Design
We designed an electronic survey using Qualtrics software to gather
data. The survey contained questions about general demographics,
2 Curr Probl Cardiol, October 2023

profession, average number of weekly ECG interpretations, previous
ECG training, the extent of expert ECG interpreter supervision, and ECG
interpretation comfort level. The survey was part of the EDUcation Cur-
riculum Assessment for Teaching Electrocardiography (EDUCATE)
Trial and was conducted according to the Consensus-Based Checklist for
Reporting of Survey Studies (CROSS) proposed by the Enhancing the
QUAlity and Transparency Of health Research (EQUATOR)
Network.
16,17
Study Participants
We recruited medical professionals aged 18 or older, who already
completed their professional training or were currently enrolled in a train-
ing program. Participants included medical students, resident physicians
(including internal medicine, emergency medicine, and family medicine
residents), cardiology fellows-in-training (FIT), primary care physicians
(including family medicine and internal medicine physicians), nurses,
advanced practice providers (APPs, including physician assistants and
nurse practitioners), and allied health professionals (including ECG tech-
nicians, emergency medicine technicians, and paramedics). Physicians
were defined as primary care physicians, cardiology FIT, and resident
physicians, while nonphysicians were defined as APPs, nurses, and allied
health professionals. Practicing cardiologists and emergency medicine
physicians were excluded.
Ethical Considerations
We obtained approval from the educational review committee and
institutional review board (IRB) at the Mayo Clinic, the IRB at Washing-
ton University School of Medicine in St. Louis, SUNY Upstate Medical
University, and Keck School of Medicine at the University of Southern
California, as well as WCG IRB, an external IRB review company. Study
approval and support was obtained from all relevant academic and pro-
fessional leadership stakeholders or committees prior to recruitment.
Survey Questions
The survey comprised of multiple questions and response items that
delved into various aspects of participants’ current ECG interpretation
practices, prior ECG interpretation education, and their inclination
towards receiving additional ECG interpretation education. Table 1 out-
lines the items included in the survey.
Curr Probl Cardiol, October 2023 3

TABLE 1. Survey respondent characteristics
CharacteristicNo. (%)
Age distribution
18-25 years 419 (17)
26-35 years 1294 (51)
36-45 years 402 (16)
46-55 years 244 (10)
>55 years 156 (6)
Sex
Female 1184 (47)
Male 1331 (53)
Location
United States 1401 (56)
Outside United States 1114 (44)
Professional group
Primary care physicians 205 (8)
Cardiology fellows-in-training 255 (10)
Resident physicians 539 (21)
Medical students 350 (14)
Advanced practice providers 211 (8)
Nurses 250 (10)
Allied health professionals 705 (28)
Physicians*999 (40)
Nonphysicians
y
1166 (46)
Average ECG interpretations
0 per week 533 (21)
1-10 per week 1338 (53)
11-25 per week 416 (17)
>25 per week 228 (9)
ECG interpretation responsibility
Directly impacts patient care 1608 (64)
Indirectly impacts patient care 381 (15)
No impact on patient care 144 (6)
Not applicable 382 (15)
ECG interpretation comfort
Uncomfortable (low) 1125 (45)
Somewhat comfortable (moderate) 1082 (43)
Comfortable (high) 308 (12)
Prior dedicated ECG training
0 hours 1133 (45)
<5 hours 709 (28)
5-15 hours 436 (17)
>15 hours 237 (9)
Expert ECG interpreter supervision
None 992 (39)
Rarely 635 (25)
Somewhat often 548 (22)
Often 232 (9)
Very often 108 (4)
*Physicians include primary care physicians, cardiology fellows-in-training, and resident
physicians.
yNonphysicians include advanced practice providers, nurses, and allied health professionals.
4 Curr Probl Cardiol, October 2023

Statistical Analysis
All survey data were exported from Qualtrics into statistical analysis
software package, MedCalc for Windows, version 19.4 (MedCalc Soft-
ware, Ostend, Belgium). We used descriptive statistics to summarize the
survey data, with nominal variables reported as a count (percent of the
total). Comparison between groups were made using the Chi-square test
based on the frequency of expected values. We considered statistical sig-
nificance with a two-tailed alpha level of <0.05.
Results
Respondent Characteristics
Table 1 provides an overview of the baseline characteristics of survey
respondents. Of 3500 medical professionals invited to take part, 2515
completed the entire survey, with 1184 (47%) of them being female.
Most participants were aged 26-34 years (1294, 51%) and from the
United States (1401, 56%). The cohort consisted of 205 (8%) primary
care physicians, 255 (10%) cardiology FIT, 539 (21%) resident physi-
cians, 350 (14%) medical students, 211 (8%) APPs, 250 (10%) nurses,
705 (28%) allied health professionals, 999 (40%) physicians, and 1166
(46%) nonphysicians.
Survey Results
Figure and Table 2 summarize survey results. All findings were consis-
tent across all medical professional groups (P<0.001) and did not vary
between (1) primary care physicians, cardiology FIT, resident physicians,
and medical students, (2) APPs and nurses, or (3) physicians and
nonphysicians.
ECG Interpretation Responsibility
Most participants (1338, 53%) reported interpreting an average of 1-10
ECGs per week. Meanwhile, 416 (17%) and 228 (9%) participants
reported interpreting an average of 11-25 and over 25 ECGs per week,
respectively. Of the 533 (21%) participants who reported zero average
weekly ECG interpretations, 219 (41%) were medical students.
A significant majority of medical professionals (1989, 79%) reported
that their ECG interpretation responsibilities have a direct (1608, 64%) or
indirect (381, 15%) impact on patient care. Only a small percentage of
Curr Probl Cardiol, October 2023 5

FIG. Survey results from all respondents, physicians, and nonphysicians. Survey responses regarding their (A) dedicated ECG training hours, (B) frequency of expert
interpreter supervision, (C) independent ECG interpretation comfort, and (D) desire for further ECG education. The top row represents the results ofallrespondents
(N = 2515). The middle row displays results of physicians (n = 999), which includes primary care physicians, cardiology fellows-in-training, and resident physicians. The
bottom row summarizes the results from nonphysicians (n = 1166), which includes advanced practice providers, nurses, and allied health professionals (Color version of
figure is available online.)
6 Curr Probl Cardiol, October 2023

TABLE 2. Respondent feedback on average number of weekly ECG interpretations, dedicated ECG training hours, independent ECG interpretation comfort,
and frequency of expert supervision
Professional group N Weekly interpretations (#) Dedicated education (hours) Interpretation comfort Expert supervision
0 1-10 11-25 >25 0 <5 5-15 >15 Low Moderate High None Rarely Somewhat
often
Often Very
Often
Primary care physicians 205 11
(5)
120
(59)
40
(20)
34
(16)
92
(45)
59
(29)
42
(20)
12
(6)
58
(28)
110
(54)
37
(18)
65
(32)
58
(28)
59
(29)
17
(8)
6
(3)
Cardiology fellows-in-training 255 6
(2)
69
(27)
102
(40)
78
(31)
105
(41)
63
(25)
46
(18)
41
(16)
38
(15)
132
(52)
85
(33)
61
(24)
72
(28)
59
(23)
37
(15)
26
(10)
Resident physicians 539 35
(7)
368
(68)
104
(19)
32
(6)
279
(52)
152
(28)
81
(15)
27
(5)
248
(46)
258
(48)
33
(6)
165
(31)
183
(34)
130
(24)
47
(9)
14
(3)
Medical students 350 220
(63)
123
(35)
5
(1)
2
(1)
167
(48)
121
(35)
48
(14)
14
(4)
262
(75)
72
(21)
16
(5)
204
(58)
77
(22)
45
(13)
18
(5)
6
(2)
Advanced practice providers 211 31
(15)
123
(58)
37
(18)
20
(9)
103
(49)
58
(28)
41
(19)
9
(4)
105
(50)
85
(40)
21
(10)
88
(42)
48
(23)
39
(19)
23
(11)
13
(6)
Nurses 250 86
(34)
136
(54)
17
(7)
11
(4)
144
(58)
68
(27)
24
(10)
14
(6)
155
(62)
81
(32)
14
(6)
153
(61)
45
(18)
29
(12)
13
(5)
10
(4)
Allied health professionals 705 144
(20)
399
(57)
111
(16)
51
(7)
243
(34)
188
(27)
154
(22)
120
(17)
259
(37)
344
(49)
102
(14)
256
(36)
152
(22)
187
(27)
77
(11)
33
(5)
Physicians*999 52
(5)
557
(56)
246
(25)
144
(14)
476
(48)
274
(27)
169
(17)
80
(8)
344
(34)
500
(50)
155
(16)
291
(29)
313
(31)
248
(25)
101
(10)
46
(5)
Nonphysicians
y
1166 261
(22)
658
(56)
165
(14)
82
(7)
490
(42)
314
(27)
219
(19)
143
(12)
519
(45)
510
(44)
137
(12)
497
(43)
245
(21)
255
(22)
113
(10)
56
(5)
All participants 2515 533
(21)
1338
(53)
416
(17)
228
(9)
1133
(45)
709
(28)
436
(17)
237
(9)
1125
(45)
1082
(43)
308
(12)
992
(39)
635
(25)
548
(22)
232
(9)
108
(4)
Group comparisons a, b, c, d a, b, c, d a, b, c, d a, b, c, d
a: P-value <0.001 between all medical professional groups (excluding physician and nonphysician groups)
b: P-value <0.001 between primary care physicians, cardiology fellows-in-training, resident physicians, and medical students
c: P-value <0.001 between advanced practice providers and nurses
d: P-value <0.001 between physicians
1
and nonphysicians
2
Values represent the number (%) of respondents.
*Physicians include primary care physicians, cardiology fellows-in-training, and resident physicians.
yNonphysicians include advanced practice providers, nurses, and allied health professionals.
Curr Probl Cardiol, October 2023 7

participants (526, 21%) reported no impact on patient care, with the
majority (350, 67%) of those being medical students.
ECG Interpretation Comfort
Most participants (2207, 88%) were uncomfortable or only somewhat
comfortable with independent ECG interpretation, while only 308 (12%)
reported feeling comfortable. This trend was consistent across all medical
professional groups, including physicians and nonphysicians. Medical
students and nurses reported the lowest comfort levels. Cardiology FIT
reported the highest level of comfort, with 84 (33%) feeling comfortable
in independent ECG interpretation.
Prior ECG Interpretation Education
Overall, most medical professionals (1842, 73%) reported receiving
less than 5 hours of dedicated ECG education during training, with nearly
half of them (1133, 45%) reporting no education. This trend was consis-
tent across participants within and outside the United States, with 1041
(74%) and 801 (72%) reporting less than 5 hours of dedicated education,
and 641 (46%) and 492 (44%) reporting no education, respectively.
Among practicing and training physicians, 1038 (77%) reported less
than 5 hours of dedicated education, with 643 (48%) reporting no dedi-
cated education during medical training. Even after excluding medical
students, there was virtually no difference, with 750 (75%) and 476
(48%) of physicians reporting less than 5 hours or no dedicated educa-
tion, respectively. Similar findings were observed from nonphysicians
with 804 (69%) and 491 (42%) reporting less than 5 hours or no dedicated
education, respectively. Similarly, 212 (85%) nurses and 161 (76%) APPs
reported less than 5 hours of dedicated education, with 145 (58%) and
103 (49%) reporting no education, respectively. In contrast, a greater pro-
portion of allied health professionals (465, 66%) reported receiving dedi-
cated education, with 276 (39%) reporting receiving 5 hours or more.
Expert ECG interpretation supervision
Table 2 summarizes the respondents’ feedback on the amount of expert
ECG interpretation supervision. Most respondents (2175, 87%) reported
limited expert ECG interpreter oversight, with 992 (39%), 635 (25%),
and 548 (22%) reporting no, rare, or somewhat frequent review of their
ECG interpretations, respectively. Even 192 (75%) cardiology FIT
reported limited expert ECG interpretation supervision, with 61 (24%),
8 Curr Probl Cardiol, October 2023

72 (28%), and 59 (23%) reporting no, rare, and somewhat frequent review
of their ECG interpretations, respectively. Only 340 (14%) medical pro-
fessionals reported receiving frequent supervision from an expert ECG
interpreter, with 232 (9%) and 108 (4%) reporting supervision often or
very often, respectively.
Desire for ECG Interpretation Training
The overwhelming majority of surveyed participants (2461, 98%)
expressed a desire for more ECG education and training.
Discussion
The issue of inadequate ECG interpretation competency among medi-
cal professionals is not a new problem. Despite the longstanding impor-
tance of ECGs to medical practice, concerns about ECG interpretation
inadequacies have been raised for nearly 50 years,
13-15
and multiple
reports have demonstrated significant deficiencies in ECG interpretation
proficiency across numerous medical disciplines.
5,7-10
Our study sheds
light on a critical reason why major shortcomings might exist.
Our investigation identified notable insufficiencies in the amount of
training and supervision provided to medical professionals in ECG inter-
pretation. Despite the acknowledged importance of ECGs in patient care
and their frequent exposure in clinical practice, our survey respondents
reported major deficits in their comfort level, training, and expert supervi-
sion in ECG interpretation. Most medical professionals reported low or
moderate comfort levels with independent ECG interpretation. A substan-
tial majority received less than 5 hours of dedicated training, with nearly
half stating they had not received any education or training. These find-
ings are particularly alarming because even among those for whom expert
supervision is a widely recommended approach, respondents reported a
lack of expert ECG interpreter supervision.
1-5
Moreover, given the seem-
ingly widespread lack of ECG interpretation education and training,
expert supervision or oversight may be the only means by which patients
receive a skilled ECG interpretation. The dual findings of inadequate
training and limited expert supervision may not only directly contribute
to poor ECG interpretation in clinical practice but also to the widespread
lack of comfort in performing ECG interpretation among medical pro-
viders, as previously reported.
5,7
Our investigation uncovers an unsettling discrepancy between the
responsibility placed on medical professionals for ECG interpretation
Curr Probl Cardiol, October 2023 9

and the amount of training and supervision they receive. In other words,
we reveal a significant gap between the training expected of medical pro-
fessionals and what is needed in real-life clinical practice.
To achieve major improvements in clinical ECG interpretation profi-
ciency, there must be commensurate improvements in the quality and
extent of education and training provided to medical professionals. Fortu-
nately, our study findings have identified significant interest among medi-
cal professionals to enhance their ECG interpretation skills through
dedicated education and training. This presents an opportunity for the
development of contemporary and standardized learning solutions tai-
lored to different learners, with the aim of bridging these gaps and pro-
moting improved ECG interpretation and patient care. Further research
should investigate various educational approaches to identify effective
methods for teaching, acquiring, and maintaining this skill.
Limitations
We must acknowledge the limitations of our work. Firstly, we relied
on self-reported data, which is susceptible to recall and response bias.
Secondly, we did not survey practicing cardiology and emergency medi-
cine providers. Although some similarities could be expected for certain
questions, we cannot generalize our findings to these provider groups.
Lastly, while our study identified deficiencies in ECG training and super-
vision, we cannot definitively conclude that these findings directly corre-
spond to low ECG interpretation proficiency among the surveyed
medical professionals.
Conclusions
This survey of medical professionals from different discipline and
training levels exposed noteworthy inadequacies in ECG interpretation
training, expert supervision, and confidence. Nearly all participants
expressed a desire for more ECG interpretation education and training.
Declaration of Competing Interest
The authors declare the following financial interests/personal relation-
ships which may be considered as potential competing interests: Author
(Anthony Kashou, MD) is the founder and CEO of The EKG Guy, and
has received research funding from GE HealthCare (Milwaukee, WI).
10 Curr Probl Cardiol, October 2023

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