Electrocardiograms, Family Physician Interpretation (Position Paper)

Overview and Justification

Introduced in 1902 by Willem Einthoven, electrocardiography is still the most commonly used procedure for the diagnosis of heart disease.1 Electrocardiograms (ECGs) are interpreted not only by cardiologists, but by other specialists, including family physicians.1

The ECG contributes significantly to the diagnosis and management of cardiac arrhythmias and the acute myocardial ischemic syndromes, the two conditions that account for the majority of cardiac catastrophes.2 The procedure itself is safe, easy to administer and available at a minimal cost.1

Although computerized interpretation of ECG data is improving and is widely available, it is not reliable enough to obviate the need for physician over-reading and confirmation.3-5 Family physicians thus cannot rely on computer-based diagnostics and must maintain competence in the task.

Section I – Scope of Practice for Family Physicians

It is the position of the American Academy of Family Physicians (AAFP) that clinical privileges should be based on the individual physician’s documented training and/or experience, demonstrated abilities, and current competence.6 The AAFP also advocates the development of specific patient-centered practice policies that focus on what should be done for the patient rather than who should do it. When policies address the issue of who should provide care, then recommendations for management, consultation or referral should emphasize specific appropriate competencies, rather than a clinician’s specialty designation.7 This perspective is in line with the policies of other organizations with influence in the area of credentialing and privileging:

  • The American Medical Association (AMA) policy on staff privileges states "Decisions regarding hospital privileges should be based upon the training, experience, and demonstrated competence of candidates, taking into consideration the availability of facilities and the overall medical needs of the community, the hospital, and especially patients. Privileges should not be based on numbers of patients admitted to the facility or the economic or insurance status of the patient. Personal friendships, antagonisms, jurisdictional disputes, or fear of competition should not play a role in making these decisions."8
  • The Joint Commission (TJC) maintains that the credentialing and privileging process should include "overview of each applicant's licensure, education, training competence, and physical ability to discharge patient care responsibilities."9

It is well established that interpretation of ECGs is within the scope of family medicine. The diagnosis and management of cardiovascular disorders is routinely taught in family medicine residency programs.10 Moreover, the most recent AAFP statistics, from 2009, show that 94.4% of family physicians perform ECGs in the office.11

Section II – Clinical Indications

Electrocardiography is the procedure of choice for patients who present with chest pain, dizziness or syncope, or for those with symptoms that may indicate risk of sudden death or myocardial infarction.2

In its 2001 statement, the Task Force on Clinical Competence formed by the American College of Cardiology (ACC), the American Heart Association (AHA), and the American College of Physicians (ACP) noted the wide variety of indications for ECG: “There are numerous potential clinical uses of the 12-lead ECG. The ECG may reflect changes associated with primary or secondary myocardial processes (e.g., those associated with coronary artery disease, hypertension, cardiomyopathy, or infiltrative disorders), metabolic and electrolyte abnormalities, and therapeutic or toxic effects of drugs or devices. Electrocardiography serves as the gold standard for the noninvasive diagnosis of arrhythmias and conduction disturbances, and it occasionally is the only marker for the presence of heart disease.”2

Electrocardiography is not indicated for screening of healthy subjects without symptoms of heart disease, hypertension, or other risk factors for the development of heart disease.2

The US Preventive Services Task Force states that for asymptomatic adults at low risk for coronary heart disease, the incremental information offered by ECG is “highly unlikely to result in changes in risk stratification that would prompt interventions and ultimately reduce coronary heart disease-related events.”12

Section III — Training Methodology 

Training for ECG interpretation begins in medical school, and is continued in the family medicine residency program curriculum. The Accreditation Council for Graduate Medical Education requires that family medicine residency training include a separate, defined critical care experience, and a structured clinical experience in cardiology.13 This would include training in the interpretation of ECGs. The depth of experience for each resident depends on the expected practice needs of the resident, especially in terms of practice location, available facilities, and accessibility of consultants. At times, the family medicine resident may find it appropriate to seek consultation from a cardiologist to either manage or co-manage a patient for optimal care.10

Physicians who wish to undergo more extensive training may want to obtain a preceptor. Preceptors may be found by contacting staff members at local hospitals who have expertise in ECG interpretation. Other sources for obtaining a preceptor include local family medicine residency programs, local Academy chapters, and local medical societies.

The AAFP’s policy titled, “Procedural Skills, Residency Criteria,” holds that training in individual procedures includes a range of elements, among them clinical indications, contraindications, mechanical skills acquired under direct supervision, and prevention and management of complications.14

Section IV — Testing, Demonstrated Proficiency, and Documentation

Testing and demonstration of proficiency in ECG interpretation may involve monitoring a physician’s interpretations or administering a test. The AAFP believes that local tests to ensure competence are appropriate as long as they apply equally to all physicians.15

The ACC/AHA/ACP Task Force recommends that to ensure continued competence, a random sample of a physician’s interpretations should be periodically reviewed,2 because there are no data to support a correlation between the frequency of unsupervised interpretations and a physician’s skill.2

Documentation of ECG interpretation in a supervised or teaching environment will help to facilitate attainment of privileges for this skill.

Section V - Credentialing and Privileges 

The process for credentialing and delineation of family medicine privileges varies among organizations. Before a physician applies for ECG privileges, his or her documentation of training, experience, and current competence should be in order.16 The following guidelines will help with the credentialing process:

  1. Collect letters of recommendation from past instructors, preceptors, those who have monitored the applicant’s clinical performance, and colleagues who have worked with the applicant throughout the years.
  2. Assemble case reports including data about the number and types of cases, treatment outcomes, etc.
  3. Assemble documentation records maintained during your family practice residency.

The physician should have complete documentation, case reports, and letters of recommendation in order at the time of application for medical staff privileges. It is important that a copy of each document be submitted and all original documents retained by the applicant, so that replacements may be sent in the event that application materials are lost or misplaced. The physician should maintain documentation of ongoing clinical experiences.16

The AAFP recommends the establishment of family medicine departments in all hospitals departmentalized by specialty. The department of family medicine should have rights, duties, and responsibilities comparable to those of other specialty departments of the medical staff. It should have the right to recommend directly to the appropriate committee those privileges which fall within the scope of family medicine. Neither the assent nor the approval of any other department should be required.17

Privileges for family physicians very often overlap those in other clinical departments, and there may be some confusion as to which department is responsible for recommending privileges. For example, a family physician may request “cardiology” privileges (in the department of family medicine) that would overlap those in the department of cardiology. The AAFP believes that the family medicine department should determine the criteria for and recommend privileges commensurate with the core curriculum and training offered in a family medicine residency program.17

Some privilege problems arise because other specialists do not understand the scope of family medicine. In addition to the need to give other specialists general information about family medicine, specific issues include the following:18

  1. Clinical privileges should be considered on the basis of each physician's documented training and/or experience, demonstrated abilities, and current competence.
  2. Many specialties overlap.
  3. No clinical privileges are the exclusive province of one department.
  4. A vital part of a family physician’s training is in knowing when to consult and when to refer patients.
  5. Continuity of care is a primary objective of family medicine, and this objective is consistent with high-quality patient care.
  6. Family physicians are supported by the AAFP in their efforts to obtain privileges for which they are qualified.

The AAFP recommends that payment for the interpretation of ECGs be available for all eligible physicians with ECG privileges, regardless of the physician's speciality.

Section VI - Miscellaneous Issues

Quality Assurance

Family medicine departments should have an ongoing peer review process in place that monitors patient outcomes to ensure that members maintain their competence.

Public Health Implications

Family physicians are often the first and sometimes the only point of contact for many patients within the health care system. Expanding and improving family physicians' skills in ECG interpretation could improve access to cardiovascular care for patient populations in need.

Research Agenda

The research agenda for ECG interpretation should focus on the following:

  1. Continued effort to document the outcomes of ECG interpretation by family physicians
  2. Effective quality improvement programs to improve interpretation error rates
  3. Continued research into training method

Formal Relationships With Other Organizations

Cooperation in the development of quality improvement programs should be encouraged between the AAFP, the ACC, and the ACP.

Section VII - Data Sources

  1. Brohet C. Value of the electrocardiographic examination. Acta Cardiol. 1999:54(4):181-185.
  2. Kadish AH, Buxton AE, Kennedy HL, et al. ACC/AHA clinical competence statement on electrocardiography and ambulatory electrocardiography: A report of the ACC/AHA/ACP-ASIM task force on clinical competence (ACC/AHA Committee to develop a clinical competence statement on electrocardiography and ambulatory electrocardiography) endorsed by the International Society for Holter and noninvasive electrocardiology. Circulation. 2001;104(25):3169-3178.
  3. Willems JL, Abreu-Lima C, Arnaud P, et al. The diagnostic performance of computer programs for the interpretation of electrocardiograms. N Engl J Med. 1991;325:1767-1773.
  4. Salerno SM, Alguire PC, Waxman HS. Competency in interpretation of 12-lead electrocardiograms: a summary and appraisal of published evidence. Ann Intern Med. 2003;138:751-760.
  5. Salerno SM, Alguire PC, Waxman HS. Training and competency evaluation for interpretation of 12-lead electrocardiograms: recommendations from the American College of Physicians. Ann Intern Med. 2003;138:747-750.
  6. American Academy of Family Physicians. Privileges [policy statement]. www.aafp.org/about/policies/all/privileges.html. Accessed July 25, 2012.
  7. American Academy of Family Physicians. Joint development of clinical practice guidelines with other organizations. http://www.aafp.org/about/policies/all/joint-development.html. Accessed August 15, 2012.
  8. American Medical Association. Opinion 4.07 - Staff privileges. www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion407.page(www.ama-assn.org). Accessed July 25, 2012.
  9. Standard MS.06.01.05. In Joint Commission on 2012 Hospital Accreditation Standards. Oakbrook Terrace, IL: Joint Commission Resources; 2012.
  10. Recommended Curriculum Guidelines for Family Medicine Residents: Cardiovascular Medicine Reprint No. 262. Leawood, KS: American Academy of Family Physicians; 2011. www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint262_Cardio.pdf(8 page PDF). Accessed July 27, 2012.
  11. American Academy of Family Physicians. Practice Profile Survey II. Leawood, KS: American Academy of Family Physicians; 2009.
  12. Screening for coronary heart disease with electrocardiography: U.S. Preventive Services Task Force Recommendation Statement. U.S. Preventive Services Task Force, July 2012. Accessed September 4, 2012. http://www.uspreventiveservicestaskforce.org/uspstf11/coronarydis/chdfinalrs.htm(www.uspreventiveservicestaskforce.org).
  13. Accreditation Council for Graduate Medical Education. Program requirements for graduate medical education in family medicine. http://www.acgme.org/acgmeweb/(www.acgme.org). Accessed August 9, 2012.
  14. Procedural skills training, residency criteria [policy statement]. www.aafp.org/about/policies/all/procedural-skills-training.html. Accessed August 10, 2012.
  15. American Academy of Family Physicians. AAFP guidelines on EKG interpretation privileges for family physicians. www.aafp.org/about/policies/all/privileges-electrocardiogram.html. Accessed August 10, 2012.
  16. American Academy of Family Physicians Handling hospital privilege problems: for family physicians who are medical staff members. www.aafp.org/practice-management/administration/privileging/resolve-problems.html. Accessed August 10, 2012.
  17. American Academy of Family Physicians. Privileges, family medicine departments and [policy statement]. www.aafp.org/about/policies/all/privileges-family.html. Accessed August 10, 2012.
  18. American Academy of Family Physicians. Family Medicine in Hospitals: Strategies for Strength. 5th ed. Leawood, KS: American Academy of Family Physicians; 2004.

(March Board 2001) (2013 COD)