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.
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:
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
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
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
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.
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:
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
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.
Family medicine departments should have an ongoing peer review process in place that monitors patient outcomes to ensure that members maintain their competence.
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.
The research agenda for ECG interpretation should focus on the following:
Cooperation in the development of quality improvement programs should be encouraged between the AAFP, the ACC, and the ACP.
(March Board 2001) (2013 COD)
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