Electrocardiograms, Family Physician Interpretation of

Overview and Justification

Introduced in 1902 by Willem Einthoven, electrocardiography is still regarded as 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 is widely available, it is often considered unreliable, making competency and interpretation by family physicians an essential skill.¹

Section I – Scope of Practice for Family Physicians

It is the position of the American Academy of Family Physicians that clinical privileges should be based on the individual physician’s documented training and/or experience, demonstrated abilities and current competence. This general policy would of course apply to privileges in all areas.³ The AAFP also advocates the development of specific patient-centered practice policies which 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 appropriate specific competencies, rather than a clinician’s specialty designation.⁴

The American Medical Association’s (AMA) policy on patient protection and clinical privileges states that the accordance and delineation of privileges should be determined on an individual basis, commensurate with an applicant's education, training, experience, and demonstrated current competence. In implementing these criteria, each facility should formulate and apply reasonable, nondiscriminatory standards for the evaluation of an applicant's credentials, free of anti-competitive intent or purpose.⁵

The Joint Commission on Accreditation of Health Care Organizations (JCAHO) maintains that the following are acceptable documentation for credentialing criteria: (1) current licensure; (2) relevant training or experience; and (3) current competence.⁶

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.⁷ Recent AAFP statistics show that 89.8% of family physicians interpret ECGs in the office setting, and that 36.0% include ECG interpretation in their hospital practices.^8-9 These same data show that only 2.9% were denied these privileges when requested.⁹

The standard 12-lead ECG is one of the most common tests obtained and interpreted in the family physician office, with most of the physicians reading their own studies and basing clinical decisions on their findings. Studies have been done that indicate that family physicians can achieve proficiency in the interpretation of over 95% of all ECG findings seen in the primary care setting.¹⁰

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

The American College of Physicians (ACP)/American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Privileges published guidelines for clinical competence in electrocardiography. The task force agreed that the following are some of the settings in which an ECG may be indicated: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

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.¹¹ 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.⁷

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 or local medical societies.

The AAFP’s Policy on Training for Clinical Procedures holds that training in individual procedures includes clinical indications, diagnostic problem solving and mechanical skills acquired under direct supervision and prevention and management of complications.¹²

Section IV - Testing, Demonstrated Proficiency and Documentation

Testing and demonstrated proficiency in ECG interpretation may be done by monitoring a physician’s interpretations or by administration of a test. The AAFP believes that local tests to assure competence are appropriate as long as they apply equally to all physicians.¹³

The ACP/ACC/AHA Task Force recommends that to ensure continued competence a random sample of a physician’s interpretations should be periodically reviewed² 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 obtaining privileges for this skill.

Section V - Credentialing and Privileges

The process for credentialing and delineation of family medicine privileges varies among organizations. Before applying for ECG privileges, the documentation of training, experience and current competence should be in order. The following are guidelines that will help with the credentialing process:¹⁵

Complete documentation, case reports, and letters of recommendation should be in order at the time of application for medical staff privileges. It is important that a copy of each document be submitted in the event that the original documents are lost or misplaced. Ongoing documentation of clinical experiences should be maintained.¹⁵

The AAFP recommends the establishment of family medicine departments in all hospitals departmentalized by specialty. The department of family medicine should have all the rights, duties, and responsibilities comparable to 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. The assent or approval of any other department should not be required.¹⁶

Privileges for family physicians very often overlap those in other clinical departments, and there seems to be some confusion as to which department is responsible for recommending privileges. For example, the family physician may request “cardiology” privileges (in the department of family medicine) that would overlap those in the department of cardiology. The chair of the department of family medicine determines the criteria for recommending privileges in the family medicine department and is responsible for reviewing the cardiology privileges of the members of his/her department.¹⁶

Some privilege problems arise because other specialists do not understand the scope of family medicine. In addition to providing other specialists with general information about family medicine, specific issues include:¹⁴

Section VI - Miscellaneous Issues

Quality Assurance

Family medicine departments should have an ongoing peer review process in place to ensure that competence is maintained by monitoring patient outcomes.

Public Health Implications

Family physicians are often the first, and sometimes only point of contact for many patients within the health care system. Expanding and improving their 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:

Formal Relationships With Other Organizations

Cooperation in the development of quality improvement programs should be encouraged between the AAFP, the ACC, and the American College of Physicians – American Society of Internal Medicine (ACP-ASIM).

Section VII - Data Sources

(March Board 2001) (2007)