• Electrocardiograms, Family Physician Interpretation (Position Paper)

    Overview and Justification

    Electrocardiography was introduced by Willem Einthoven with the first published electrocardiogram (ECG) in 1902.1 It is the most commonly used test for the diagnosis of heart disease2, contributing significantly to the diagnosis and management of cardiac arrhythmias and acute myocardial ischemic syndromes, which account for the majority of cardiac catastrophes.3 An ECG is safe, easy to administer, and available at a minimal cost.2

    Electrocardiograms are interpreted not only by cardiologists, but also by other specialists, including family physicians. Although computerized interpretation of ECG data is widely available and is improving, it is not reliable enough to obviate the need for physician over-reading and confirmation.4,5,6 Therefore, family physicians must maintain competence in ECG interpretation.

    Section I – Scope of Practice for Family Physicians

    According to the October 2016 AAFP Member Profile, 89% of active American Academy of Family Physicians (AAFP) members perform ECGs in the office7, and it is well established that ECG interpretation is within the scope of family medicine. The diagnosis and management of cardiovascular disorders is routinely taught in family medicine residency programs. The AAFP’s recommended cardiovascular medicine curriculum guidelines for family medicine residents state: “Core cognitive ability and skill may be obtained through longitudinal or block rotations, or cardiology experiences in intensive care and cardiac care units. Residents will obtain substantial additional cardiology experience throughout the three years of experience in the family medicine practice, on their family medicine inpatient service, and through internal medicine experiences. During this time, it would be a reasonable goal to accomplish proficiency in ECG interpretation and [cardiopulmonary resuscitation (CPR)].” 8

    Section II – Clinical Indications

    Electrocardiography is indicated for patients who present with chest pain, palpitations, dizziness, or syncope, and for those who have symptoms that may indicate risk of sudden death or myocardial infarction.2,9

    In 2001, the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine (ACC/AHA/ACP-ASIM) Task Force on Clinical Competence released a statement on electrocardiography and ambulatory electrocardiography. This statement (which had not been updated as of September 2017) notes 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 who do not have symptoms of heart disease, hypertension, or other risk factors for the development of heart disease. The U.S. Preventive Services Task Force (USPSTF) states that for asymptomatic adults at low risk for coronary heart disease (CHD) events, the incremental information offered by an ECG is “highly unlikely to result in changes in risk stratification that would prompt interventions and ultimately reduce CHD-related events.”10 Under the Choosing Wisely campaign—a national effort to reduce waste in the health care system and avoid unnecessary or harmful tests and treatment—the AAFP recommends that physicians should not order annual ECGs or any other cardiac screening for low-risk patients who do not have symptoms.11 This recommendation is based on evidence that shows false-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment, and misdiagnosis, so potential harms of routine annual ECG screening exceed the potential benefit.

    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 (ACGME) requires that family medicine residency training include specific subspecialty training to ensure competence in the care of the cardiology patient in family medicine, which would include training in the interpretation of ECGs.12 AAFP policy states that procedural skills training in the family medicine residency should comprise a number of components, including knowledge of clinical indications and contraindications, and performance under supervision.13 Specific to training for ECG interpretation, the ACC/AHA/ACP-ASIM Task Force on Clinical Competence states that physicians should gain basic knowledge of electrocardiographic technology, cardiac anatomy, and cardiac physiology, and learn how to recognize diagnostic patterns on a 12-lead tracing.2 The number of studies needed to obtain competence in ECG interpretation has not been established.2,3

    The depth of ECG experience a family medicine resident requires will depend on his or her expected practice needs, especially in terms of practice location, available facilities, and accessibility of consultants.Physicians who wish to undergo more extensive training may find a preceptor by contacting local hospitals to identify medical staff members who have expertise in ECG interpretation. Other resources for finding a preceptor include local family medicine residency programs, AAFP chapters, and medical societies.

    Section IV — Testing, Demonstrated Proficiency, and Documentation

    Testing a physician’s knowledge of indications for ECG and ECG interpretation is a part of the general testing for certification by the American Board of Family Medicine (ABFM).14 Primary certification and recertification examinations include questions on topics such as arrhythmia interpretation, diagnosis of ischemia/myocardial infarction, and structural issues (e.g., accessory pathways). The number of questions about ECG interpretation varies from examination to examination.

    Maintaining competence in ECG interpretation requires ongoing practice.2 However, the amount of continuing experience in ECG interpretation needed to maintain proficiency has not been extensively studied. Proficiency in ECG interpretation may be determined by monitoring a physician’s interpretations or administering a test. It is the AAFP’s position that if local tests are utilized to establish current competence, the use of such tests should apply equally to all physicians, regardless of specialty.15

    The AAFP recommends that family physicians document all significant training and experience so that it is recorded and can be reported in an organized fashion.16

    Section V - Credentialing and Privileges 

    The process for credentialing and delineation of family medicine privileges varies among organizations. It is the position of the AAFP that clinical privileges should be based on the individual physician’s documented training and/or experience, demonstrated abilities, and current competence.17 AAFP policy states, “On the basis of their training in family medicine, family physicians should have the education, training, and experience to read electrocardiograms and should therefore be eligible for privileges to interpret [ECGs].”18

    The AAFP’s stance 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 patient protection and clinical privileges states, in part, “Concerning the granting of staff and clinical privileges in hospitals and other health care facilities, the AMA believes: (1) the best interests of patients should be the predominant consideration; (2) 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.”19
    • The Joint Commission's standards also require that the decision to grant or deny privileges, and/or to renew existing privileges, must be an objective, evidence-based process in which there are no barriers to granting privileges for a given activity to more than one clinical specialty. The Joint Commission Comprehensive Accreditation and Certification Manual for 2017 states, “Credentialing involves the collection, verification, and assessment of information regarding three critical parameters: current licensure; education and relevant training; and experience, ability, and current competence to perform the requested privilege [MS.06.01.03].”20 All of the criteria regarding licensure, education, training, and current competence should be "consistently evaluated for all practitioners holding that privilege [MS.06.01.05].”20

    The AAFP supports the establishment of a family medicine department in every hospital departmentalized by specialty. 21 The department of family medicine should have the right to recommend directly to the appropriate committee all privileges that fall within the scope of family medicine, including ECG interpretation. Neither the assent nor the approval of any other department should be required.

    Because privileges for family physicians often overlap those in other clinical departments, there may be some confusion about 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 of the department of cardiology. 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.21

    Resources on hospital privileging, including information about avoiding privileging disputes and answers to frequently asked questions about hospital credentialing and privileging, are available from the AAFP.

    Section VI - Miscellaneous Issues

        A.    Payment

    The AAFP recommends that payment for the interpretation of ECGs be available for all eligible physicians who have competence in ECG interpretation, regardless of the physician's specialty.

        B.     Quality assurance

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

        C.    Public health implications

    Family physicians are 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.

        D.    Research agenda

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

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

        E.     Relationships with other organizations

    The AAFP, the ACC, and the ACP should cooperate to develop quality improvement programs for ECG interpretation.

    Section VII – References

    1. Einthoven W. Galvanometrische registratie van het menschilijk electrocardiogram. In: Herinneringsbundel Professor SS Rosenstein. Leiden, the Netherlands: Eduard Ijdo; 1902:101-107.\
    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. Balady GJBufalino VJGulati MKuvin JTMendes LASchuller JL. COCATS 4 Task Force 3: training in electrocardiography, ambulatory electrocardiography, and exercise testing. J Am Coll Cardiol. 2015;65(17):1763-1777.
    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. Schläpfer J, Wellens HJ. Computer-interpreted electrocardiograms: benefits and limitations. J Am Coll Cardiol. 2017;70:1183-1192.
    7. American Academy of Family Physicians. AAFP Member Profile. Leawood, KS: AAFP; October 2016.
    8. American Academy of Family Physicians. Recommended curriculum guidelines for family medicine residents: cardiovascular medicine reprint no. 262. 2011. Accessed September 22, 2017.
    9. Schlant RC, Adolph RJ, DiMarco JP, et al. Guidelines for electrocardiography: a report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Electrocardiography). Circulation. 1992;85:1221-1228.
    10. U.S. Preventive Services Task Force. July 2012. Accessed September 22, 2017.
    11. Choosing Wisely®. Annual EKGs for low-risk patients. Accessed September 22, 2017.
    12. Accreditation Council for Graduate Medical Education. Program requirements for graduate medical education in family medicine. Accessed September 22, 2017.
    13. American Academy of Family Physicians. Procedural skills training, residency criteria [policy statement]. Accessed September 22, 2017.
    14. Hagen M. American Board of Family Medicine, Senior Vice President. Personal communication, September 2017.
    15. American Academy of Family Physicians. Privileges, electrocardiogram interpretation [policy statement]. Accessed September 22, 2017.
    16. American Academy of Family Physicians. Privileges, documentation of training and experience [policy statement]. Accessed September 22, 2017.
    17. American Academy of Family Physicians. Privileges [policy statement].   http://www.aafp.org/about/policies/all/privileges.html. Accessed September 22, 2017.
    18. American Academy of Family Physicians. Privileges, electrocardiogram interpretation [policy statement]. Accessed September 22, 2017.
    19. American Medical Association. Patient protection and clinical privileges H-230.989 (reaffirmed 2009). Accessed September 22, 2017.
    20. The Joint Commission. Joint Commission Comprehensive Accreditation and Certification Manual for 2017. Oak Brook, Ill.: Joint Commission Resources; 2017.
    21. American Academy of Family Physicians. Privileges, family medicine departments and [policy statement]. Accessed September 22, 2017.

    (March Board 2001) (2018 COD)