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Friday, August 12, 2005

IM and EM residents and EKG reading-overall competency score is low-AJM article

A disconcerting article appeared in the August 2005 issue of the American Journal Of Medicine.
87 internal medicine residents and 33 emergency medicine residents were given 12 test ekgs to read. The residents were from two institutions and all residents were exposed to formal training in EKG reading. Unfortunately the manner in which the results are displayed is a bit confusing, it uses a"proficiency score",which to me obscures more information than it illuminates, but the bottom line is that neither group did very well. One table shows that of all the residents (IM and EM in one grouping) only 40% had the correct answer for an acute MI.(52% had a partially correct answer-what ever that is and only 8 percent had it wrong, apparently they gave partial credit.) So it is hard to figure out how many could or could not recognize an acute MI. But the authors, who we assume did understand the data, concluded the overall competency score was low. Further,they reported that their results were similar to several other studies that evaluated EKG reading skills in house staff.
I find it amazing that any number of IM residents greater than zero were unable to diagnose a typical acute MI or V. Tach. In medical school, our senior year we had a course in EKG interpretation and we all purchased a small text by Dr.George Burch on that subject. As IM residents we were conversant in the details of the proposed minutiae of the differential diagnoses of V. Tach. vrs supraventricular tachycardia with aberration.Interestingly, we had no formal courses on EKG interpretation as residents. Further,The chief of surgery made sure that his residents could recognize the EKG patterns of acute MI as he walked the walk of his theme that surgeons were physicians who knew how to operate.
I am reminded of a blog reference to an article in which it was noted that of 259 IM residents who were tested regarding ventilator use, about half did not know how to set the tidal volume in an ARDS patient. I also recall an Annals of Internal Medicine article which-although it emphasized other aspects of the story-revealed the apparent ignorance of house staff in realizing the importance of evaluating a upper lobe infiltrate in an alcoholic with weight loss and cough for TB.
I realize these are limited, possibly biased samples and from them it may be not appropriate to hypothesize a trend that suggests woefully inadequate training in internal medicine. I really do not want to believe that. I read about an IM program that is now two years post internship rather than three. I read that ACGME has devised requirements that necessitate more being crammed into this shorter time frame. Residents must now learn "system based practice" and quality improvement projects may be required and the time they can spend in the hospitals is restricted and , yes, there is simply more medical knowledge out there to learn.
I know that older professionals in many fields seem to always think the newer generations cannot live up to the standards that the old guard set, that the new kids have it easier, are soft and do not know as much. I'm sure I am guilty of that mind set, but-my goodness-an internist has to know how to read a EKG and if I were an EM resident knowing I would see chest pain patients every day, I would make sure I could recognize an acute MI ekg pattern and not wait to have a lecture on the topic to become proficient. I hope that this article does not accurately reflect the ekg interpretation skills of residents in IM and EM.
And another thing, sometimes I think that physicians believe that reference to evidence based medicine must always be made even if the application seems gratuitous. The authors of the article say in the purpose section " yet there are no evidence based guidelines for assessing [ekg reading] competency". How about just giving them ekgs and seeing if they can interpret them? We really don't need and will never have EBM guidelines for everything.


Anonymous said...

Our small contribution to educating the residents is the mnemonic A RARE PQRST -> DR. IIEE . It can be used to remember the systematic approach when reading an EKG.

james gaulte said...

The URl for " a rare pqrst..." didn't work,I'd like to know what it stands for thanks
James Gault

Clinical Cases said...

I am sorry, the code got jammed during the cutting/pasting of the link:


Or you can just Google for A RARE PQRST -> DR. IIEE...